'.;\'V5!>T' ■
jc^^wcj^x, flK. g .
\<\
MEDICAL AND SURGICAL WORKS.
LECTUEES on SUKGICAL PATHOLOOY.
Delivered at the Eoyal College of Surgeons of England. By Sir James Paget,
Bart. F.R.S. D.C.L. Oxon. &c. Serjeant-Surgeon Extraordinary to the Queen.
Third Edition. Eevised and Edited by W. Turner, M.B. Lond. Professor of
Anatomy in the University of Edinburgh. 8vo. with 131 Woodcuts, price 21s.
ANATOMY, DESCEIPTIVE and SUKGICAL.
By Henry Gtray, F.R.S. late Lecturer on Anatomy at St. George's Hospital.
With nearly 400 large Woodcuts after original Drawings from Dissections.
The Seventh Edition, by T. Holmes, Surgeon and Lecturer on Surgery, St.
George's Hospital. With an Introduction on GENERAL ANATOMY and
DEVELOPMENT, by the Editor. Royal 8vo. price 285.
The SCIENCE and AET of SUEQEEY.
A Treatise on Surgical Injuries, Diseases, and Operations. By John Eric
Erichsen, Senior Surgeon to University College Hospital, and Holme Professor
of Clinical Surgery in University College, London, Sixth Edition, with 712
Wood Engravings. 2 vols. 8vo. price 32s.
On CONCUSSION of the SPINE in its CLINICAL and
MEDICO-LEaAL ASPECTS.
By John Eric Erichsen, Senior Surgeon to University College Hospital, and
Holme Professor of Clinical Surgery in University College, London. 1 vol.
crown 8vo. [Nearly ready.
A SYSTEM of SUEOEEY, THEOEETICAL and PEACTICAL.
In Treatises by various Authors. Edited by T. Holmes, M.A. Surgeon and
Lecturer on Surgery at St. George's Hospital. Second Edition, with numerous
Woodcuts, Lithographs, and Chromo-lithographs (in all 472 Illustrations).
5 vols. 8vo. price £5. 5s.
Vol, I. price 2 Is. General Pathology.
Vol. II. price 21s. General and Special Injuries.
Vol. III. price 21s, — Diseases of the Eye and Ear, of the Organs of Circula-
tion, Muscles, and Bones.
Vol. IV. price 21s. — Diseases of the Organs of Locomotion, of Innervation,
of Digestion, of Eespiration, and of the Urinary Organs.
Vol. V. price 21s. — Diseases of the Genital Organs, of the Breast, Thyoiod
Gland, and Skin ; Operative Surgery, &e.
The ESSENTIALS of MATEEIA MEDICA and THEEA-
PEUTICS.
By Alfred Baring Garrod, M.D. F.E.S. &c. Professor of Materia Medica
and Therapeutics, King's College, London. Fourth Edition, revised under the
supervision of the Author, by E. B. Baxter, M.D. Crown 8vo. price 12s. 6d,
DE. PEEEIEA'S MATEEIA MEDICA and THEEAPEUTICS.
Abridged, and adapted for the use of Medical and Pharmaceutical Practitioners
and Students. Edited by Professor K, Bbntley, M,R,C.S. E.L,S, and by
Professor T. Redwood Ph.D. F.C.S. 8vo. with 126 Woodcuts, price 255.
Medical and Surgical Works.
A TEEATISE on the CONTINUED FEVERS of GREAT
BRITAIN.
By Charles Mtjbchison, M.D. LL.D. F.R.S. &c. Fellow of the Royal College
of Physicians ; Physician and Lecturer on the Principles and Practice of
Medicine, St. Thomas's Hospital. Second Edition, thoroughly revised and
enlarged; with 5 Chromolithographs, 19 Diagrams in Lithography, and 22
Illustrations engraved on Wood. 8vo. price 245.
LECTURES on the PRINCIPLES and PRACTICE of PHYSIC.
Delivered at King's College, London. By Sir Thomas Watson, Bart. M.D.
&c. Physician in Ordinary to the Queen. Fifth Edition, Revised and Enlarged,
with 2 Plates. 2 vols. 8vo. price 365.
LECTURES on DISEASES of INFANCY and CHILDHOOD.
By Charles West, M.D. &c. Physician to the Hospital for Sick Children
Sixth Edition. 8vo. price 185.
The DIAGNOSIS and TREATMENT of DISEASES of
WOMEN.
Including the DIAGNOSIS of PREGNANCY. By Grailt Hetvitt, M.D.
Professor of Midwifery and Diseases of Women at University College. Third
Edition. With numerous Illustrations (several new). 8vo. price 245.
QUAIN'S ELEMENTS of ANATOMY.
Seventh Edition. Edited by William Sharpey, M.D. F.R.S. Professor of
Anatomy and Physiology in University College, London ; Allen Q'homson,
M.D. F.R.S. Professor of Anatomy in the University of Glasgow ; and John
Cleland, M.D. Professor of Anatomy in Queen's College, Galway. Illustrated
by upwards of 800 Engravings on Wood. 2 vols. 8vo. price 3l5. 6d,
DENTAL PATHOLOGY and SURGERY.
By S. James A. Salter, M.B. F.R.S. Member of the Royal College of Surgeons,
and Examiner in Dental Surgery at the College; Dental Surgeon to Guy's
Hospital. AVith 133 Woodcut Illustrations. 8vo. 18s.
DISEASES of the KIDNEY and URINARY DERANGE-
MENTS.
By W, ilowsHip Dickinson, M.D. Physician to and Lecturer on Pathology at
St. (Jeorgc's Hospital. Part I. — Diabetes. With 3 Plates of Figures and 17
Woodcuts. 8vt>. price lO.s. 6d.
NOTES on the TREATMENT of SKIN DISEASES.
By Rorkkt LivKiNf!, M.A. M.I). &c. Physician to the Middlesex Hospital.
Second Edition, with Additions. 18mo. price 2s. 6d.
London, LONGMANS & CO.
CLINICAL
LECTUEES AND ESSAYS.
LONDON : PRINTKD IIY
SPOTTISWOODK AND CO., NEW-STKKET SQUAKE
AND PARLIAMENT STKEBT
CLINICAL
LECTUEES AND ESSAYS
BY
SIR JAMES PAGET, BART,
F.R.S., D.C.L. OxoN., LL.D. Cantab.
SERJEANT- SURGEON EXTRAORDINARY TO HER MAJESTY THE QUEEN,
SURGEON TO H.R.H. THE PRINCE OF 'WALES,
CONSULTING SURGEON TO ST. BARTHOLOMEW'S HOSPITAL.
EDITED BY
HOWARD MAESH, F.R.C.S.
ASSISTANT-SURGEON TO ST. BARTHOLOMEW'S HOSPITAL AND TO THE
HOSPITAL FOR SICK CHILDREN.
LONDON :
LONGMANS, GEEEN, AND CO.
1875.
All rights reserved.
TO MY BROTHER
GEOEGE EDWARD PAGET, M.D., E.R.S.
REGIUS PROFESSOR OF PHYSIC IN THE
UNIVERSITY OF CAMBRIDGE
IN TOKEN OF GRATITUDE
BOTH FOR Ills LOVE
AND FOR HIS GOOD EXAMPLE HELP AND COUNSEL.
PEEPACE.
f
-•O*-
The greater part of the contents of this book have
been ah^eady pubhshed in Medical Journals, or in
Hospital-Eeports. I hope that I atn not wrong in
publishing them again in this form.
I do not suppose that the book contains much, if
anything, whicli is not known to those who are in large
surgical practice, or familiar with surgical literature ; but
it is not intended for these. Its chief purpose will be
attained if it be useful to students and to those who
have too few opportunities of studying surgery in either
large practice or large books.
Of the many faults in the book of which I am con-
scious, faults of both matter and style, none seems to
me greater than the apparent disregard of the works of
others. I beg pardon of all whom I may thus offend.
viii PREFACE.
I would not have been guilty of this fault if I had had
time for reading as well as practice.
Mr. Howard Marsh, besides relieving me of the usual
troubles of an editor, has done what he can in an
appendix of notes to amend the chief of my defects.
1 Harewood Place, Hanoyer Square,
March 1875.
CONTENTS
-•o«-
PAGE
The various Kisks or Operations (Lancet, 1867, vol. ii.) . . 1
The Calamities of Surgery (Clinical Lecture, 1868) , . .51
Stammering with other Organs than those oe Speech (British
Medical Journal, 1868, vol. ii. p. 437) 77
Cases that Bone-setters cure (British Medical Journal, 1867,
vol. i. p. 1) 84
Strangulated Hernia (British Medical Journal, 1872, vols, i., ii.) . 101
Chronic PviEMiA (St. Bartholomew's Hospital Reports, vol. i. p. 1) . 155
Nervous Mimicry (Lancet, 1873, vol. ii.) 172
Treatment of Carbuncle (Lancet, 1869, vol. i.) . . . . 252
Sexual Hypochondriasis (Clinical Lecture, 1870) .... 268
Gouty Phlebitis (St. Bartholomeiv's Hospital Reports, vol. ii. p. 82) . 292
Residual Abscess (St. Bartholomew's Hospital Reports, 1869, vol. v.) . 310
Dissection-Poisons (Lancet, 1871, vol. i. p. 735, 774) . . . 321
X CONTENTS.
FA6&
QriET Necrosis (Clinical Society's Transactions, vol. iii. p. 138) . . 339
Sen'Ile Scrofula (St. Bartholomew" s Hospital Beports, vol. iii. p. 412) 344
Scarlet Fever after Operations (British Medical Journal, 1864,
vol. ii. p. i>37) ........... 349
Notes for the Study of sojie Constitutional Diseases . , 353
Notes 399
Index 418
OLIMOAL LECTURES AND ESSAYS.
THE VARIOUS RISKS OF OPERATIONS,
LECTUEE I.
Students are always warned against a devotion to the
operating theatre. And there is some wisdom in the
warning ; but it is very generally neglected. The reasons
for liking to see operations are so many and strong and,
for the most part, so bad, that it is useless to argue against
them. I will therefore try to turn to good use your taste
for operations, by trying to provoke you to study a sub-
ject connected with them which is not less important than
the art of operating — the subject, namely, of the influence
of various conditions of patients on the consequences of
operations performed on them. You hear me talk in
the wards of bad and of good subjects for operation, and
of greater and less risks of life ; and in one case I express
fears of the effects of shock ; in another, of erysipelas ; in
another, of slow and imperfect healing : and you may
fairly ask to be taught what, in all these matters, I pro-
fess to know or believe. In this and some following,
lectures I will try to teach you ; not because I can tell
you more than is known by most of those who are largely
l-( B
/
2 VARIOUS RISKS OF OPERATIONS
engaged in surgery, but because I cannot refer you to
any book in which you may learn nearly so much upon
the matter as you ought to know.
The average risk of life from the effects of any sur-
gical operation may be estimated from tables such as
are published in our hospital-reports. And, if an opera-
tion be frequently performed, the variations of its risk
in each sex, and at different times of life, maybe similarly
estimated as averages. But it is not within the capacity
of tables to supply the means of reckoning the variations
of risk dependent on the great variety of personal con-
ditions that we have to do with among the sick. Tables
cannot yet tell the several or united influences of dif-
ferences of constitution, of sound or unsound health, of
diseases of internal organs, of race and temper and habits
of life. Yet the • question of the safety of an operation
may turn on these very things. And not only of its
safety, but of its utility ; for there are some cases in
which operations are improper, not because of the risk
of life, but because the patients have such peculiarities
of constitution that they would suffer more pain or loss
of time or of health from an operation than even the cure
of their disease would justify. In short, you will find
that, if you are to do more good than harm by operative
surgery, you must acquire skill in detecting, and, if pos-
sible, amending, the defects of health which make opera-
tions unsafe or unsatisfactory.
Now, first, we ought to have a good standard of
healtli to which we might refer as tlie fittest for bearing
operations. Sucli a standard is not to be found among
those who, on some reckonings, might be taken for
IN THE STRONG AND THE FEEBLE. 3
models of health — those, namely, who have excellent
health for either pleasure or an active working life.
These are not the best for recovery from operations.
Amputations for injuries of limbs, which are, of course,
performed for the most part on persons injured while in
good health, are about twelve per cent, more fatal than
similar amputations for diseases. And the apparent dis-
advantages of full health which this fact illustrates are
to be seen not only in the greater mortality of similar
operations, but in the manners and rates of healing of
those who recover. You may see two amputations done
on the same day : one, say, on a strong man whose limb
has just been crushed ; the other on a man utterly en-
feebled by old disease of a joint. And then, you may not
rarely see, that the healing of the strong man requires a
much longer time, and is interrupted by many more un-
toward events, than that of the weak one.
Do not let me, however, seem to imply by these facts
that health is, in itself, a worse condition than disease is
for recovery from injuries. It is far more probable that
the comparative ill doing of the healthy is due to their
circumstances. They have to bear the shock of their
injury as well as of the operation ; their mental distress
is much greater than that of those who are relieved from
disease ; they are subjected to a great and sudden change
of habits, and have to give up many of the customs by
which they sustained the health that was fit for pleasure
or for work. Especially they have to give up the active
mental and bodily pursuits in which they excreted largely
the large refuse matter of their foods and tissue- waste.
But, however this may be, they from whom we might
b2
4 VARIOUS RISKS OF OPERATIONS
take standards of health for some purposes do not supply
such standards for studying the consequences of opera-
tions. Where then shall we find the lowest rates of mor-
tahty and other mischiefs ? Perhaps you may find them
in a class whom you may often study here. We have a
large number of printing-offices in the neighbourhood of
the hospital ; and every office employs many boys from
twelve to sixteen years old; and hardly a week passes but
we have one or more of these boys brought-in crushed
by the printing-machines. Fingers, hands, and arms are
thus mutilated ; and I know no class of patients that re-
cover more remarkably. Not only do they not die, but
their wounds heal steadily and quickly ; they escape
erysipelas and spreading suppurations and secondary
hasmorrhages ; and often, when, to save any piece of a
hand, we leave bits of skin that seem as if they could not
live, they yet do live and grow good scars.
I know no class of persons who are better subjects for
operations than these boys. As Mr. Callender ^ has pointed
out, our success with them helps to bring us the credit of
a very low rate of mortality in amputations of the upper
extremity. You may, however, find individuals, whom I
cannot classify, who do bear operations even better. For
operations in boys are commonly followed by very sharp
traumatic fever, which wastes and weakens them, tlioiigh
it rarely does more harm. But occasionally one meets
with patients in whom even a severe operation is followed
by neither fever nor any other trouble whatever. I can
give you no exact general description of such patients,
l)ut I believe you will find them among those who, except
* ' St. Bartholomew Hospital Ileports/ vol. y. p. 248.
IN CHILDREN. 5
for some local disease requiring the operation, are of
sound health, and whose disease, without disturbing their
natural tranquillity of mind and constitution, has induced
them to live as invalids, carefully and very temperately,
never exhausting themselves. They are naturally cheer-
ful healthy persons, to whom an operation brings no
great change of habits, but promises release from great
unhappiness.
Taking these as the best subjects for operations, and
believing that the best possible recovery is one in which
the wound heals without inflammation and without fever,
we may speak of others as good, or not bad, or bad, or
very bad — terms too ill-defined indeed, but as accurate as
any knowledge of mine will justify me in using.
Among the various differences of patients, difference
of age is probably that with which we may connect the
most regular average difference in capacity to bear opera-
tions. I believe that, after two or three years old, the in-
crease of age is attended with a proportionate increase of
liability to death and other ill consequences of operations.
Our hospital-reports and all similar tables will show you
this ; but there are many things within the general rule
that you should learn.
Young and healthy children are chiefly in danger
through the shock of operations, and they bear pain very
ill — it adds much to the danger of the shock. But if the
shock and pain be well passed, they are in less risk than
older patients. Especially, they are singularly little liable
to pyasmia after wounds — a strange contrast to their
liabilitv to it in association with acute necrosis.-^
1 See Note I.
6 VARIOUS RISKS OF OPERATIONS
But the chief interest in connection with age is in the
cases of old persons, for among them are patients in whom
nearly every risk of operations rises to its maximum.
Nor will this seem strange if you consider how many dis-
ad vantages for the bearing of injuries old age brings with
it. The Ion oner a man lives after middle ao^e, the more
likely is he to have some organic disease, the more cer-
tain is he to have inany degeneracies. Hence, to name
one source of trouble, the tardy circulation, and the
various congestions due to mere sinking of the blood, not
in the lungs alone, but in the liver and intestines and all
otlier dependent parts — facts to be much considered in
regulating the postures of old people after operations.
But the extreme of mifitness for injuries you may see in
some of the poor old creatures on whom we are forced,
l)y glimmers of hope, to operate for hernia. They are so
near death that, temper it as we may, the least shock
kills them.
But among the old there are even greater differences
than among the younger in the ability to recover from
operations ; and age, if reckoned by years, is not the only
thing in them that we must estimate. Years, indeed,
taken alone are a very flxllacious mode of reckoning age :
it is not the time, but the quantity, of a man's past life
that we have to reckon; and for this esthiiate, with a
practised eye, looks are less deceptive than a tale of
years. Even among those old patients to whom you
cannot impute disease you may easily, by their appear-
ances, mark out some groups very different in their bear-
ing of injuries. They tliat are fat and bloated, pale, with
soft textures, flabby, torpid, wheezy, incapable of exer-
IN OLD PERSONS. 7
cise, looking older than their years, are very bad. They
that are fat, florid, and plethoric, firm-skinned, and with
good muscular power, clear-headed, and willing to work
like younger men, are not indeed good subjects for opera-
tions, yet they are scarcely bad. The old people that are
thin and dry and tough, clear- voiced and bright-eyed,
with good stomachs and strong wills, muscular and active,
are not bad ; they bear all but the largest operations very
well. But very bad are they who, looking somewhat
like these, are feeble and soft-skinned, with little pulses,
bad appetites, and weak digestive power ; so that they
cannot, in an emergency, be well nourished.
I have said that all the risks of doing badly are at
their maximum in some among the old ; but these are
some of the risks for which they will always need your
especial care. The old are, much more than others,
liable to die of shock, or of mere exhaustion within a few
days after the operation. They bear badly large losses
of blood, long exposure to cold, sudden lowering of
temperature, loss of food. Large wounds heal in them
lazily ; and hence a prolonged liability to secondary
hgemorrhage and other mischiefs of open wounds. Their
stomachs, too, are apt to knock-up with what may seem
to be no more than necessary food, though indeed it
often is so ; for many old people are in less peril with a
scanty diet than with a full one. Their convalescence is
often prolonged ; and you may expect to meet sometimes
with great disappointment in having your old patients
die with some slight casual disease, as if exhausted by the
long expense of vital power in healing large wounds.
They get all but well ; and then, after seeming for some
8 VARIOUS RISKS OF OPERATIONS
time stationary, they fade and waste and die. They fulfil
what I have often told you of the diseases of the aged :
that there are some to whom convalescence is more dan-
gerous than disease.
These special dangers of the old will suggest to you
some special cares for them. You must choose for them,
if you can, short and gentle operations ; and be sparing
of haemorrhage ; and make wounds that may not lead to
long suppurations. You must keep them warm, and not
feed them beyond their real necessities, nor keep them
lone: recumbent. Your cares must be doubled when
your operations are on the lower limbs, or the lower part
of the trunk, or on the back, for in operations on these
parts the risks, both local and general, are much greater
than in the parts above the heart.
In saying these things about the old, I have had in
view only those patients who may call themselves ' well
for their age,' and in whom you may find no signs of
disease. Infirmities they have — degenerations and de-
cays accumulated and perhaps premature, yet not dis-
eases. Now let me add, that of all the conditions of
disease or imperfect health of which I have next to speak
as infkiencing tlie results of operations, there is no graver
complication than old age, unless, indeed, it be habitual
intemperance.
And first as to the infiucnce of various constitutions
and chronic constitutional diseases, supposing them to l)e
unattended with any considerable organic disease, except
that which requires the operation.
Scrofulous patients, whether old or young, have, I
tliink, no special liability to the fatal consequences of
IN SCROFULOUS PERSONS. 9
operations, except in so far as tliey are feeble and may
die (though they rarely do) through slow exhaustion, or
the gradual development of some internal organic disease.
The relief from pain and the removal of irritation com-
monly seem more than enough to compensate for the
shock and other depressing influences they are at first
submitted to. They seem not very liable to pyemia,
erysipelas, or other of these sore plagues. All this you
may see often enough in our cases of excision of joints ;
and in these same you may also see, better than in any
others, what are the defects of the scrofulous constitution
in reference to recovery from operations. The wounds
heal very slowly ; the cellular tissue is apt to become very
cedematous and ' gummy ; ' the scars are thin, and often
break down and ulcerate ; the deeper cuttings become
sinuous, with tedious discharges of thin pus, and wasting.
In a word, the half-healed wounds are apt to become
like scrofulous ulcers ; and if the patients remain long
uncured, their constitutional scrofula is increased by long
confinement, and perhaps by hospital-air.
Thus, you may sometimes find (but it ought to be in a
small minority of cases) that scrofulous patients seem to
be, if I may so speak, made more scrofulous by the
removal of a diseased limb or joint. And this is, no
doubt, the explanation of some of the cases which have
led to a belief often entertained, that the removal of
scrofulous disease from one part induces its occurrence, or
aggravates it, in another. There are, indeed, some cases,
especially among the middle-aged and older, in which the
two events do seem to stand in direct relations. You
may have seen last year a girl in Sitwell, whose forefinger
10 VARIOUS RISKS OF OPERATIONS
was removed for scrofulous disease of one of its joints.
The wound had scarcely healed before similar disease
ensued in a knee-joint, which was somid before the
removal of the finger. So, I have seen a patient, one
of whose toes was removed for scrofulous disease ; then a
knee became similarly diseased, and the limb was ampu-
tated above it ; and soon after this, caries of part of the
spine ensued. Eecovery from this last disease has been
followed by no further outward appearance of scrofula.
Such sequences, however, are not to be certainly ascribed
to the operations. Eecently, a patient long under treat-
ment, with scrofulous disease of the elbow, and with the
sinuses healing, has had scrofulous disease of the spine,
and this has seemed to advance while the disease of the
elbow has improved.
The study of the relation of these successions of
similar disease in different parts is one in which you may
do good and gain honour ; but tlie event is so far m-
frequent that, except in the intensely or the acutely
scrofulous, or those who are not young, you need not fear
it. In the large majority of cases, especially the chronic
cases,, the removal of a scrofulous part is followed by im-
proved health. Still, remember, the operation is finally
effective only against that part ; the patient may remain
scrofulous, and may need the same constitutional treat-
ment after, as before, the operation. Therefore, before
you operate, make sure, if you can, tliat the patient,
especially if he is old, is one who can stand prolonged
confinement. Have this in mind when you luive a choice
between two or more operations ; and, after the operation,
take care that tlie patient*s general condition is lielped
IN S YP HI LI TIC PERSONS. 1 1
with fresh air and fit food and cleanliness and all other
good means that you can provide.
The scrofulous patients of whom I have been speaking
are such as may be considered very liable to tuberculous
disease, though having none actually present — at least in
any internal organ. Of the actually tuberculous I will
speak hereafter, especially in relation to the risks of those
who are phthisical. But now to speak of others.
You will sometimes have to operate on syphilitic
patients ; and you will find them not bad subjects, except
in so far as their syphilis may have made them very
feeble or cachectic or, in rarer cases, may have affected
their internal organs.
Incisions through, or within the range of contact of,
inoculating sores will be inoculated and become chan-
crous ; but I have seen no worse mischief than this in
those with primary syphilis. I am not sure that I ever
operated on any one with active secondary syphilis ; but
I have done so in many who have had sores of tertiary
syphilis, and have afterwards had renewed tertiary
symptoms. But they recovered as well as any other
patients of equal general strength, and none of the
wounds became like syphilitic ulcers.
In this respect, indeed, the contrast between scrofula
and syphilis, as affecting the consequences of operations,
may seem very striking ; but I suspect that, in a larger
number of cases than I have had, some wounds would
become seats of syphihtic disease,^ for it is not rare to find
cases in which nodes and necrosis and tertiary ulcers have
^ Such a case is reported by Mr. Simon in the ' Twelfth Eeport of the
Medical Officer of the Privy Council/ 1869, p. 39.
12 VARIOUS RISKS OF OPERATIONS
had their origin in blows and other rough injuries done to
syphihtic people.
I have never had occasion to operate on a patient
with acute rheumatism. In those with chronic rheu-
matism, or subject to it, I have seen no mischiefs that
could be ascribed to their constitutional defects.
Of the gouty, in reference to their capacity to bear
operations, I think that much worse has been said tlian
they deserve. I have, in at least three instances, seen
patients attacked with acute gout shortly after capital
operations ; and the progress of good recovery was in
none of them impeded. One of these cases w^as that
of a fat, plethoric, active man, from whom I cut-out
a cancerous breast. On the next day gout set in with
a furious severity — worse than he had ever had it ; yet
his wound healed, and he recovered from all the effects
of his operation as well as any healthy person could have
done.
I have seen no greater troubles in patients whom I
have known to be subject to gout or born to it ; and I
therefore believe that the disrepute of gout for making
men unfit for operations is due to the fact that, as gouty
people grow old, they become, sooner and more certainly
than others, subject to degeneration of the kidneys, heart,
arteries and other internal organs. These, and not
merely gouty disposition or constitution of the blood, im-
pair their power of bearing injuries and operations. Look
sharp for these organic defects and avoid tliem, and then,
I believe, you will find your gouty patients as fit for ope-
rations as others of the same ages and habits of life, pro-
IN GOUT; IN CANCER; IN PLETHORA, 13
vided, of course, that you correct, as far as you can, any
actual disturbances of function. Operations may bring
out their gout (as the saying is), but will not endanger
their lives.
Cancerous patients are certainly not bad subjects for
operations, or, at least, not worse than others of similar
age and general condition. Many, indeed, being operated
on in the early stages of the disease, are, for their age, in
a full average of general good health ; and even in those
on whom operations are advisable though they are
cachectic, it is often remarkable how well their wounds
heal, and what a revival of power they display.
These, so far as I have been able to learn them, are
the various risks of patients with admitted morbid consti-
tutions. The importance of being able to decide the
questions arising in such cases must be evident to you.
And questions of equal importance, and of yet greater
difficulty, arise in the cases of many who may not be
called diseased, but who certainly are not, in any just
sense of the word, healthy. Such are the plethoric, the
over-fat, the intemperate, the over-fed, the feeble, the
degenerate, the cold-blooded. What can be safely said
about these, and of the dangers they severally incur when
we wound them ? I will try to tell what I believe.
Plethora, pure and simple, is not a bad condition for
operations. So far as I have seen, people that have been
fidl-blooded, ruddy, warm, round-limbed, tight-skinned,
with strong hearts, and, as we suppose, a rather excess of
blood, have done well. But such people must be care-
fully managed ; not fed too well ; not kept too long in
14 VARIOUS RISKS OF OPERATIONS
bed ; not allowed to retain their refuse ; and mere bigness
must not be taken for plethora.
For the over-fat are certainly a bad class, especially
when their fatness is not hereditary, but may be referred
in any degree to their over-eating, soaking, indolence, and
defective excretions. The worst of this class are such as
have soft, loose, flabby, and yellow fat, and I think you
may know them by their bellies being pendulous and
more prominent than even their thick subcutaneous fat
accounts for ; for this shape tells of thick omental fat
and, I suppose, of defective portal circulation. I know
no operations in which I more nearly despair of doing
good, than in those for umbihcal hernia or for compound
fractures in people that are over-fat after this fashion.
Nothing short of the clearest evidence of necessity or
of great probable good should lead you to advise cut-
ting operations in people of this kind. Do lithotrity
for them rather than lithotomy ; incline against ampu-
tations for even bad compound fractures ; and, wherever
you can — as, for instance, for cutaneous cysts, hasmor-
rlioids, and the smaller examples of scirrhous mammary
cancers, — use caustics rather than the knife or ligature.
All these warnings must be doubled for the intempe-
rate. One does, indeed, sometimes meet with habitual
drunkards who pass safely through the perils of great
operations ; but these are rare exceptions to tlie rule, ac-
cording to which one may reckon that the risks of all
operations increase with tlie increasing degrees of habitual
intemperance. I think you will iiiid that a habit of slight
intemperance is nmcli worse than occasional great ex-
cesses ; that regular soaking is worse than irregular carous-
IN DRUNKARDS; IN TEETOTALERS. 15
ing ; probably because of the steady impairment of the
blood and of all the textures to which the soaking leads.
Of course, you will keep your hands off notorious drunk-
ards, unless you are driven by the stress of a strangulated
hernia, or a stopped windpipe, or something leaving you
as little choice as these do. But you must be on your
guard to detect a good deal of drunkenness of the soak-
ing kind which is not notorious and not confessed. Be
rather afraid of operating on those, of whatever class,
who think they need stimulants before they work ; who
cannot dine till after wine or bitters ; who always have
sherry on the side-board ; or are always sipping brandy-and-
water ; or are rather proud that, because they can eat so
little they must often take some wine. Many people who
pass for highly respectable, and who mean no harm, are
thus daily damaging their health, and making themselves
unfit to bear any of the storms of life. Especially they are
doing so, who increase their stimidants while they diminish
their food. This is a fatal error, much worse than that
of both eating and drinking in excess.-^
On all such as these, operations are more than doubly
hazardous. Of course you may hear of wondrous escapes
from dangers, and, on the credit of a few exceptions, silly
proverbs are made about the impunity of drunkards ; but
the general rule is certain. Every risk of an operation is
increased in the habitually intemperate ; they are, above
the average, liable to every one of all the sources of
danger and of death.
I have had no sufficient experience among teetotalers
to enable me to speak with any certainty of their capacity
1 See Note II.
i6 VARIOUS RISKS OF OPERATIONS
for bearing operations. I cannot doubt that a patient
trained, all his hfe, to habits of rigid temperance would
bear injuries of all kinds much better than the average of
men ; but people of this sort are not commonly those
with whom you have to do under the name of teetotalers.
These are, much more commonly, such as have been in-
temperate or, to say the least, imprudent, in their manner
of living, and have then wholly changed their habits, and
lived without any stimulants whatever. Of such people
I have no good opinion when they come to be the sub-
jects of surgery ; for they seem to retain the bad liabilities
of the intemperate long after they have given up their
bad habits. I would not adopt the opinion that I have
heard some express, that teetotalers are worse patients
than drunkards ; but I should always expect that a very
long period of reformation would be required to free a
man from the damages he has sustained by intemperance.
Over-eating is not commonly supposed to lead to any
such risks of life as over-drinking does ; yet I believe
that you will find, in operative surgery, that among the
habits that increase the risks of life, this may stand not
far off drunkenness, especially if the over-eating is of meat
and other nitrogenous foods. I am led to believe this
from several cases that I have observed, and I think that
there are large evidences of it. You know that the gen-
eral results of operations in provincial hospitals tell of a
smaller mortality than in the hospitals of London and
the largest towns. The difference is commonly ascribed to
differences in the purity of the air, and other advantages of
that kind in the comparatively rural districts. I believe
that much more of it is due to the differences of habits
IN DIFFERENT RACES. 17
in the several classes of patients.^ The differences are
many ; but one of the chief of them is that the poor in
the agricultural districts eat far less meat than those in
large towns do, and are, by comparison, less fed though
probably not worse fed ; and you may frequently observe
that patients who come to us from agricultural districts
bear operations in all respects better than Londoners who
are submitted to the same proceedings. Of course many
things concur to make the differences of constitution be-
tween a town- and a country-population ; but I am
satisfied that among these things a very potent influence
is exercised by the difference of diet. And the differences
that we may thus see are strongly illustrated by what
one hears of the results of operations upon the natives
of India and other Eastern countries, whose diet is almost
exclusively vegetable. Almost any amount of injury may
be inflicted on them and not be followed by the de-
structive mischiefs which occur in Europeans under the
same circumstances. They are defective, it is said, in
healing power ; but they recover with comparative cer-
tainty, however slowly, from operations of the greatest
magnitude. A common expression about them is, ' You
can't kill them.^
There are many patients to whom you cannot assign
a morbid constitution, but who are feeble in all their
processes. No organ, it may be, works wrongly ; but no
organ works with due power. Many children are in this
condition, and some aduhs, whose condition has been
admirably portrayed by Dr. Chambers in his book^ on
* See a paper by Mr. Callender in ' St. Bartholomew Hospital Reports,'
vol. V. p. 244, et seq.
^ See note III. ' Climate of Italy, 18G5, p. 8, et seq.
C
1 8 VARIOUS RISKS OF OPERATIONS
Italy. They are not always bad subjects for operation.
Eepair will probably take place in them as feebly as any
other vital process ; but I believe they are not particu-
larly liable to those diseases after operations from which the
greatest risks arise. Children of this class you should be
cautious of operating upon for hare-lip or other such
defects as do not urgently require interference ; and in
adults, if you can defer operations to some period of
better health, you should do so ; but all this for fear of
local failure rather than for incurring any unusual risk
of life. For in the management of these, as of all cases,
you will find that the chief vital risks of operations are
not through mere defects of power, but through diseases.
The measure of danger is not in the proportion between
more or less of vital force, and more or less of exhaustion,
but in the amount of liability to real diseases of the blood
and tissues.
You often hear me speak of patients as ' cold-blooded.'
I do not know that the whole of their blood is less warm
than that of ordinary persons, but some of it is, for their
hands and feet are seldom or never naturally warm ; and
some of them feel, when you touch them, as cold as rep-
tiles in the same climate — their hands and feet feel as
moist and damp as toads and frogs. The circulation in
all these cold parts is of course very slow, and probably
it lias not a due velocity in any of their textures ; for
wherever you can see vascular parts in them they are of
duller tint than they should be, dusky, and with a purple
hue rather than a rosy one ; and with these signs you
find small pulses, and general indications of slowness in
all vital processes. They digest slowly, and are very
IN THE ' cold-blooded; in the nervous. 19
prone to constipation ; and the women among them
menstruate disorderly, and are liable to headaches and
backaches, and a variety of nervous symptoms. People
of this kind are so numerous that you will do well to
look-out for them among your cases, and to treat them
specially with iron, with particular regard to this cold-
bloodedness and slowness of life. They are not bad
subjects for operations ; rather, I should reckon them
amongst the good ones ; for they have always seemed
to me singularly little liable to fall into the troubles of
erysipelas or pyaemia, or any other disorders of the
blood ; and the healing of their wounds is not apt to be
interrupted. Observe their defects ; minister to them with
warmth and good food, but not with stimulants or great
eating, and they will do as well as any you will have.
And, to finish this account of the influence of diseased, |
or disorderly, constitutions on the results of operations, 1
let me tell you of the people that are commonly called .
' nervous.' I do not refer to those who manifest disease
in any part of their nervous system, but those that are
exceedingly sensitive, mobile, and excitable, whether in
their sensitive or motor organs — who are very emotional,
and with their whole cerebro-spinal nervous system alto-
gether too alert. You will find them and their friends
always apprehensive of the results of operations ; they
will tell you that they are so nervous they can bear no
shock ; and they look with the greatest apprehension
upon the infliction of any injury. All this is fallacious.
You may be surprised at observing how very little in-
fluence upon their organic processes this excessive viva
city of their cerebro-spinal system exercises. Time after
c 2
20 VARIOUS RISKS OF OPERATIONS.
time I have found patients who have complained of
agonies in t}ieir wounds, and I do not doubt have felt
them, but whose pulses have been unmoved. They have
had enormous pain, but no fever, no single sign of dis-
turbance of their general nutrition ; they have had spas-
modic movements of their limbs, tremblings, and rigors,
but no mischief has followed. Besides, the same mobility
of mind which makes these patients very fearful before
an operation makes them hopeful directly after it ; and
amongst all the people that can in any sense be called
invalids, I know none who more generally pass through
the consequences of operations with impunity than do
those who are commonly called nervous, and whose ner-
vousness consists, if I may use the expression, in too
great a vivacity of their whole cerebro-spinal system.
Sometimes you may be forced to operate during the
continuance of an acute disease ; and although the cir-
cumstances of the case may give you httle choice as to
whether you should operate or not, it is well to be aware
of the degree in which the acute disease may iniluenc
tlie result of your proceedings.
Patients with ague bear operations as well as others
of the same class ; but, in the course of their recovery,
they may alarm you by having one or more ague-fits,
exactly resembling those that precede pya3mia. And
n:iore than this : if a patient has ever had ague and, even
many years afterwards, you perform an operation on him,
ague may seem to be renewed in him at some short time
after the shock, or loss of blood, or whatever other
damage he may have sustained. I have so often noticed
this that, whenever I hear of severe rigors following any
IN ERYSIPELAS, IN ACUTE DISEASE. 21
operation, I ask for a previous history of ague ; and I
have sometimes found that the patient has almost for-
gotten it in the long lapse of time since he suffered
from it.
The question of amputation often arises when the
patient is suffering with erysipelas, or with that spreading
inflammation of the cellular tissue which is closely akin
to erysipelas. I have often said to you that I look upon
a secondary amputation as a confession of either a mis-
take or a disappointment. Either a primary amputation
ought to have been done, and by mistake it was left un-
done, or if for any apparently sufficient reason it was not
done, the necessity of doing the secondary amputation
implies the disappointment of just hopes. I have spoken
with this disparagement of secondary amputations because
the necessity for them is so likely to come when the pro-
bability of success is reduced by the operation being per-
formed while the patient is in acute disease. I cannot
tell you the numerical increase of risk ; but I believe that
the mortality after amputations during erysipelas, or
spreading cellular inflammation, would be found very
much greater than that of primary amputations, or of
secondary amputations done for merely wasting suppura-
tion or irreparable local damage. I scarcely know any
set of cases in which I have operated v^th less hope than
in those of compound fracture, or similar injuries, in
which the question is raised whether a patient, who seems
dying with acute disease, may have what is called a
chance of his life by amputation. In the large majority
of such cases the chance by operation seems to me less
than that of keeping the patient alive by the ordinary
22 VARIOUS RISKS OF OPERATIONS
treatment of erysipelas, or whatever other acute disease
he may be suffering with.
What are the chances of recovery from operations
done during pyaemia ? I think I can answer safely, that
with acute pygemia, in which the patient has rigors once
or more in a few days, and profuse sweatings with very
rapid pulse and breathing, and \vith dehrium, and rapid
wasting, or with dry tongue and yellowness of skin, or
any considerable number of these symptoms, the proba-
bility of good is so small, and of harm so great, that you
should refuse to operate. But in chronic pyaemia, when
the disease requiring operation adds largely to the ex-
haustion from which the patient is suffering, the removal
of the disease may be very proper. Suppose, for ex-
ample, a patient with a crushed foot or a crushed hand,
in whom signs of acute pyasmia have recently appeared.
Whatever be the state of the injured part, I would not
add the damage of an amputation to the burden that the
patient already has to bear. But if the pyaemia have
become chronic, attended with only wasting and sweat-
ing and the formation of abscesses here and there, and if
the injured part be manifestly useless, or a source of
irritation or of exhaustion, the mere existence of pyaemia
in the chronic form would not turn me from the opera-
tion required by the part.
Tlic occasions for operating in any other than these
acute diseases are not many, but in diphtheria or croup
you may have to perform tracheotomy, and during peri-
tonitis a hernia may require operation. These are all
cases of necessity, and their results are not materially
affected by the general acuteness of tlie disease. If their
IN DIPHTHERIA. 33
local good is accomplished, the healing of the wound and
the recovery of the patient may occur as in any ordinary
case, unless, indeed (which I have never seen), a wound,
after tracheotomy,^ should itself become diphtheritic.
1 I have known the particulars of upwards of fifty cases in which tra-
cheotomy was performed in children suffering with diphtheria, and I have
never seen the wound attacked by the disease. Trousseau says (Victionnaire
de Med. 1835) that in the course of an epidemic he has seen leech-bites,
slight cuts, blisters, and excoriations in various parts of the body, and
different wounds, become diphtheritic. And Dr. Squire (Reynolds' Syst. of
Med. vol. i. p. 388) makes a similar statement. — [Ed.]
24 VARIOUS RISKS OF OPERATIONS
LECTUEE 11.
Ix the last lecture I told you what I believe about
the various degrees of risk incurred by persons of various
ages, habits, and constitutions when submitted to surgical
operations. The questions involved in trying to estimate
these risks are very difficult, even in their simplest forms ;
and the difficulties are subject to manifold increase,
when, as commonly happens, varieties of habit, consti-
tution, and general disease are variously intermingled.
Nor can they be Hmited even within these complications ;
for often we have to operate when local diseases add
their interferences to those of peculiarities of constitution
or of habits.
I refer to all these difficulties, not to magnify the
value of anything that I can tell you, but to justify my
speaking doubtfully on many points, and talking of belief
rather than of knowledge. I must thus speak, especially,
when referring in this lecture to the influence of local
diseases on the risks of operations ; for of these no man's
life can be long enough, busy enough, and thoughtful
enough to enable him to gather such experience as can
justify positive assertion. I cannot pretend to have
attained to more than such belief as, being vague, we
vaguely express by speaking of impressions more or less
strong. I might doubt whether such beliefs should be
promulgated, if it were not certain that much of our
IN DYSPEPSIA. 25
most useful practice is founded on similar beliefs. We
may be very ready to call them knowledges ; but tliey
do not deserve the name, and yet we must practise in
accordance with them ; just as in all the affairs of
ordinary life, when certainty is not attainable, we are
bound to act upon the highest probabihty that we can
discern.
With this understanding let me tell you what I can
of how various local diseases influence the results of
operations.
Amongst affections of the organs of digestion, I have
no experience whatever of the influence of organic dis-
ease of either the stomach or intestines. From ordinary
gastric dyspepsia, associated with a moderately healthy
condition of other organs, you will very rarely find any
serious results on the consequences of operations. I have
seen nothing worse than vexation from flatulence, heart-
burn, and the like symptoms of what we suppose to be
mere functional derangement of the stomach. They
need that the patient should be carefully dieted, but
nothing more. But I believe that dyspepsia may become
a serious complication in any of the very few cases in
which large feeding is necessary, especially if it be such
dyspepsia as is often attended with vomiting. You should
always inquire about such symptoms as even occasional
vomiting ; for besides those troubles that may arise after
operations, I think that of an untoward bearing of ether
and chloroform must be reckoned as amongj its risks.
Certainly, some of the worst effects of chloroform I have
seen, with long-continued vomiting, and the consequent
great exhaustion, have been in persons in whom it ap-
26 VARIOUS RISKS OF OPERATIONS
peared to have aggravated a natural irritability of
stomach. Eem ember, too, what I have said about feeble
digestive powers in old persons, and how their stomachs
are apt to fail after operations.
Among the diseases of the intestines, dysentery and,
even, the effects of dysentery long past, prove themselves
very grave complications. They were so, especially, in the
Crimean war ; happily, in civil practice, we very rarely
have to consider them.
The nearest likeness to dysentery which we see is
acute diarrhoea. Except in cases of urgency, you will,
of course, never operate till this is checked ; but in urgent
cases, especially in those of irritative fever with cellular
inflammation, diarrhoea adds largely to the risk. And so
it does, I think, in patients in whom it precedes the
descent of a hernia that becomes strangulated. This is a
more frequent event than you might suppose, and it seems
to me always dangerous when, soon after the strangula-
tion of a hernia is relieved, the bowels act irritably and
with copious liquid evacuations. It is one of the many
instances in which you Avill find, when dealing with
strangulated hernia, that you are not dealing with merely
mechanical difl[iculty in the intestines, but with some
disease which has produced or favoured the strangula-
tion, and upon which your operation has no good effect
whatever. Besides, speedy movements of the bowels
after operations for hernia are, I think, always injurious.^
They destroy the quietude which is requisite for the re-
covery of all the disturbed and damaged parts.
An accidental diarrhoea is only serious when it hap-
pens in persons much exhausted. In those that are
1 See note IV.
IN DIARRHOEA, IN CONSTIPATION, 27
habitually subject to diarrhoea, if an attack of it happens
after an operation, it is not likely to do any harm: But in
children and in old people, and in those that are exhausted,
diarrhoea may be very serious ; especially it may be so in
children, in whom it comes on after operations of all
kinds, and in whom you must check it abruptly with
opium or any other means. ^
I hardly need tell you that it is well to have a
patient's bowels properly open before an operation
(everybody looks to that), and to see that, as far as
possible, the intestinal secretions are healthy. The tra-
dition of this necessity is not likely soon to fade-out at
St. Bartholomew's. And if I do not refer to the subject
more fully, it is only because the rule for it comes within
the much larger rule that, so far as may be possible,
the secretions of all the organs of the body should be set
right, or kept right, before a patient is subjected to any
risk from injury. But, respecting constipation, I think
its importance has been over-stated. Eepeatedly, after
operations for hernia, I have observed that no patients
do better than those in whom, without any sign of abid-
ing strangulation, the bowels do not act for four, five, or
even more days after the operation. And in cases of
operation for fissured perineum and vesico-vaginal or recto-
vaginal fistula, in which one used formerly more than now
to keep the bowels at rest for many days, I never saw any
general disturbance of the health due to the mere in-
action of the bowels. It was, indeed, often remarkable
that while the action of the bowels was arrested for ten,
twelve or more days, the patient passed through the
ordinary process of recovery from the operation in
^ See note I.
28 VARIOUS RISKS OF OPERATIONS
exactly the same manner, with the same reaction, the
same recovery from reaction, and the same gradual re-
gaining of power, as those do whose bowels act daily.
From mere constipation, therefore, you need not antici-
pate any generally bad result. I do not recommend you
to be altogether unmindful of it ; but you need not, as
some do, consider it the matter of chiefest importance.
There is, however, a risk from constipation against which
you must very carefully guard. In some people a diffi-
cult or very copious action of the bowels is an exhaust-
ing process ; and in these the exhaustion, after many
days' inaction, may be a serious matter. Therefore
always give directions that in their cases, and, indeed, in
all cases after constipation, wine or food is to be given
after, or even during, any great action of the bowels.
I believe I have known a life lost through neglect of this
rule. The patient was a very feeble person whose breast
had been removed. She was habitually costive, and her
bowels had not acted for five or six days. Then, after
some slight aperient, there came a profuse action. Shortly
after, she had a rigor ; and then pyaemia set-in, of which
she died. And in another case, after compound fracture,
a patient, who seemed a healthy man, twice, after con-
siderable evacuations of the bowels, had such collapse as
seemed for a time to imperil his life. Guarding your-
selves against these risks, I think you may look upon
constipation as an inconvenience to the patient rather
than any serious addition to his risks.
Among diseases of the di^^cestive organs which occur
in sufficient frequency to affect the risks of dying after
operations, I suspect that none are of greater importance
IN LIVER-DISEASE. 29
than those of the hver. Of course, one's experience of
them cannot be sufficient to define the several degrees of
risk connected with each disease. As a general rule,
however, you should be cautious in operating upon those
whose biliary secretions are habitually unhealthy ; or
those who have been often jaundiced ; or those who bear
that sallow, dusky complexion, with dry skin, and dilated
small bloodvessels of the face, and sallow, bloodshot con-
junctiva, which commonly tell of what is supposed to be
an ' inactive liver.' Many of this last class are not tem-
perate ; many are sedentary and indolent ; many suffer
habitually with hasmorrhoids ; probably, all have some
abdominal plethora ; probably, all their digestive organs
act as ill as their skins do. But whatever we may guess
to be the special defect of these organs, you need not
doubt that operations upon those who have them are
attended with more than the average risk, and that when
you are obliged to operate you must do so with more
than ordinary care and caution. And there are graver
diseases of the liver than these, which you must look to ;
especially the enlargement of the liver, whether amyloid
or fatty, which is not rarely coincident with chronic
diseases of the bones in children and young persons.
This is undoubtedly a frequent cause of death after re-
section and amputation, from which in healthy children
the mortality is so small. In some, it merely seems to
hinder recovery, and they die slowly exhausted ; in some,
I believe you will find it the chief reason for such defec-
tive healing as leads to secondary ha3morrhage. The
fear of consequences such as these may give you the rule
never to operate for chronic diseases of bones or joints
30 VARIOUS RISKS OF OPERATIONS
without a specially careful examination of the liver ; for
although its diseases may be comparatively most frequent
in young patients, they may be found at any age.
Diseases of the heart are, on the whole, much less
serious hindrances to recovery from operations than you
might suppose. Doubtless, patients with very weak fatty
hearts are in some greater danger from chloroform than
others are ; but when it is cautiously given, even these
may take it safely ; and I have never heard or seen any-
thing that would make me think the administration of
chloroform specially dangerous in any such patients with
diseased hearts as a reasonable man would think of oper-
ating on. I have known it administered to patients with
considerable valvular disease without any appearance of
danger ; and certainly, in any such case, the risk of chlo-
roform would be less than that of the pain and alarm
attending any considerable operation performed without it.
The shock of an operation has a greater than its
ordinary risk in one whose heart is feeble, or embarrassed
by valvular obstruction ; and those with feeble hearts will
ill bear much loss of blood. But when these risks are
past, patients with diseased hearts have appeared to me
not prone to any dangerous complication. And there is
probably good reason for this — namely, that as soon as
the shock of an operation is over, less than the natural
force of heart is sufficient for all the purposes of life of a
patient wlio lies quietly in his bed, or whose activity is
reduced mucli Ijelow that wliich was customary with
liiiii. Do not let me seem to say that weak and diseased
hearts are trivial matters in these or in any other cases.
I would only have you believe tliat they are not such
IN HEART-DISEASE. 31
grave affairs as, at first thought, or without experience of
them, you might suppose. At any rate, I have never
seen anything to make me suppose that defective circula-
tion makes a man specially liable to pyasmia, or any other
of the chief perils after operations.
While speaking of diseases of the heart, let me tell
something of certain manners of its acting, even when we
believe its structure to be healthy. People with slow
pulses bear operations just as well as those who, in all
other respects than that of their heart's action, are like
them. And people with habitually rapid pulses are not
bad patients if the rapidity of the pulse be not associated
with some organic disease. Especially, you will find a
considerable number of children and young persons,
chiefly sensitive girls, whose pulses are rapid enough to
frighten you. Observe whether the respirations are in
the same proportion rapid ; if they are not, the respira-
tions, and not the pulse, must be your guide in judging
what is the patient's state. Many a time I have pointed
out to you a pulse beating 120 or 140 times in a minute,
and said that it meant no mischief because the respirations
were not more than twenty or twenty-five. And the
same may be said of some who, with some strangeness of
nervous system, have hearts that rapidly and widely vary
their rates of acting. I had a patient, about twenty-five
years old, with a pulse usually at eighty. I amputated his
foot for strumous tarsus, and, in any mental disturbance,
his pulse would be from 140 to 160, and was rarely
under ]20. His temperature ranged from 101° to ]05° ;
but his respirations never exceeded twenty-four ; and his
recovery from the operation was quick and unhindered.
I
32 VARIOUS RISKS OF OPERATIONS
There is a set of cases in which you must always apply
this rule of checking the indications of the pulse with
those of the breathing — namely, cases of haemorrhage.
After large bleedings, when the patient recovers from
their immediate effects, the pulse is usually hastened, and
the breathing is retarded ; so that with a pulse of 120 or
more there may be not more than ten respirations in the
minute.
Mere irregularity of the pulse, if it be habitual and
not connected with valvular disease or degeneration of the
heart, does not, so far as I know, affect the chances of
recovery from operations. If the structure of the heart,
as well as its functions, be disordered, you must judge
according to such rules as I have just stated.
The influence of diseases, or rather of degeneracies, of
arteries is not easy to measure, for the cases are com-
paratively few in which one would have to operate on
patients whose arteries are degenerate, and in whom
other important structures are sound. In the large ma-
jority of cases, degeneracy of arteries coincides with that
of many other organs, and to these, rather than to the
state of the arteries, the greater risks must be ascribed.
In the large number of old persons in whom one has to
operate for hernia, or for cancerous growths about the
face and skin, one sees no reason to suppose that arterial
degeneration is in itself a very grave matter ; nor, again,
in lithotomy. But the case is very different with ampu-
tation, especially of the lower extremity. Here one can
have no doubt that the degeneracy of the arteries in the
limb brings great peril with it. Primary hsemorrhage is
rendered more difficult to control, and recurrent and
IN DISEASES OF ARTERIES, AND VEINS, 33
secondary haemorrhage are more frequent, and all the
worse because the patients are those in whom large losses
of blood are dangerous. Moreover, if these risks are
survived, the feeble nutrition of the wounded parts gives
opportunity for spreading suppurations ; and all the heal-
ing processes are slow ; and hereby all the perils of the
case are prolonged. And when you think of slow healing
in any amputated limb, remember that, amongst all the
textures of the limb, few are less favourably constructed
for heahng than are the tissues of the arteries. Their
healing after wounds is, as you know, difficult and often
interrupted even in the healthiest persons. Much more
likely is it to be so in those whose textures are degenerate :
indeed, if you look at a thoroughly degenerate artery, you
must wonder that healing should ever take place. Out
of this difficulty of healing comes a great part of the
reasons why amputations of the lower extremities are so
fatal — so nearly hopeless — when performed for injuries in
very old people. I speak, here, only of cases in which
there is general degeneration of arteries. Special dangers
are connected with the disease of a single artery requiring
ligature, as for aneurism ; but into this, which is of itself
a very large subject, I cannot now enter.
Diseases of the veins are so generally local that they
have little bearing on any question as to the general risks
of operations. I believe that it adds not a little to the
risk of an amputation if you have to cut through varicose
veins ; but whether the diffiise plilebitis, which one has to
fear, is more often connected with previously diseased
veins than with previously healthy ones, I cannot tell.
Diseases of the respiratory organs bear with very un-
34 I^rSKS OF OPERATIONS
equal and uncertain force on the risks of operations. Of
course one can speak only of the influence of the more
common and chronic diseases ; for no one would think of
operating during any acute disease, unless in dire necessity.
Chronic bronchitis, or that which has more often to
be considered, a great tendency to bronchitis, is a grave
complication ; not because it originates serious mischief,
but because, if such mischief come from other sources,
the bronchial difficulty adds very largely to the danger.
I have never seen reason to believe that bronchitis renders
patients more liable to er3^sipelas, pyaemia, or any such
disease of the blood ; but if these happen, or indeed if
any complication comes on after an operation, the im-
perfect respiration, the restlessness, the loss of sleep, and
all the other troubles of bronchitis, diminish, by many
degrees, the chances of recovery. And so, too, bronchitis
must be feared especially in old people whose convales-
cence is not quite complete, and still more in those among
tliem who have had erysipelas about the head and face.
All these things must make you reckon that a patient
habitually subject to bronchitis, and I suppose I may
say also, a patient with emphysematous lungs, is one
in whom all operations are extremely hazardous, and
all the more so because few elderly people who have em-
physematous lungs are quite sound in their other internal
organs. The guards which you must set in any such case
in which you liave operated are evident. Especially you
must look to the air ; for these are the cases, more than
any others, in which you must try to accomplish the dif-
ficulty of providing air which is at the same time pure
and warm and moist.
• IN BRONCHITIS, AND PHTHISIS. 35
But the great interest of the diseases of the respiratory
organs, in their relation to operative surgery, is in the
question as to what may be done with a patient who has
both phthisis and some local disease that can be surgically
removed, or in any way cured, by an operation.
It has often been suspected that the removal or cure
of some local disease of a phthisical person may badly
influence the disease, of the lungs. I know no sufficient
evidence for such a suspicion, if it be meant that phthisis
is made worse by the mere fact of the cure of any other
disease ; as if the diseased part were something like an
excretory organ, the removal of which would throw an
increased labour of excretion on the lungs or some other
part. But, certainly, the fever and other accidents that
may follow an operation may do special harm to a tuber-
culous patient. You saw, not long ago, an illustration of
this. A man was under my care with a large chronic
abscess in his axilla — a strumous abscess it might be
called. It was emptied ; and, after refilling and a second
emptying, the sac was injected with diluted tincture of
iodine. This caused, as we intended, inflammation of the
sac ; but with this there came general feverish disturbance,
and through this, as it seemed, the man was found one day
suddenly almost deprived of the power of speech, and
then other cerebral symptoms followed, and after a few
days he died insensible. His death was due to inflamma-
tion of part of his cerebral membranes, where tubercular
deposits were foimd. These had been quiet so long as
his general system was calm, but with the excitement of
fever they became fatally active.
The fear of such a calamity as this should dissuade
d2
-,6 /^ISKS OF OPERATIONS
J
hJ^
you from all operations of mere convemence, and from
all measures of what may be called decorative surgery
in phthisical people ; but it should not always dissuade
you from operations that will cure diseases from which
they suffer much, and by which their lives are wasted,
as they are by fistula and diseases of bones and joints.
In these and the like cases, the main question is,
whether the local disease — say, a diseased joint — is
weighing on the patient so heavily, or aggravating his
j^hthisis and shortening his life so much, as to justify an
operation attended with more than the average risk of
life and health. Of course, the weight of each local dis-
ease must be separately judged ; but in reference to the
risks of operations, cases of phthisis must be divided into
two classes which, by comparison, may be called acute
and chronic, or progressive and suspended, phthisis.
In all cases of acute or progressive phthisis great risk
is incurred by almost every operation. The risks of the
excitement of m.any days of feverish disturbance, and of
loss of food, and of pain, and all such consequences of
operations, are much above the average ; to say nothing
of the special chances of exciting some pneumonia. I
cannot doubt that I have seen patients whose acute
phthisis has become more acute, and others in whom the
early stages of phthisis were accelerated, by the conse-
quences of operations. Therefore I should follow the
rule of never performing any considerable operation, if I
could help it, on any person whose phthisis is in quick
progress. Small things may be done on them for the
relief of great distress or pain ; but larger things had
])etter be left undone, even if they should never be done
at all.
IN ACUTE, AND IN CHRONIC PHTHISIS.
37
The case is very different with chronic and sus-
pended phthisis. In these it is often advisable to incur
the somewhat increased risk of even a large operation, in
order to free the patient from the distress and wasting of
a considerable local disease such as that of a joint ; and
I should be disposed to say that it is always advisable to
cure, if you can, a small disease such as fistula. I say if
you can, for you will often be disappointed. In the
tuberculous, as in the strumous, your wounds will remain
for weeks unhealed and, perhaps, be unsoundly healed
at last. Still, as to the mere question of operating, I
have seen so many advantages accrue to patients with
chronic phthisis from the removal of limbs with joint-
disease that I am disposed to speak strongly as to the
general propriety of whatever operations they may rea-
sonably require. For instance, I still sometimes see a
man about the hospital from whom I remember that, at
least fourteen years ago, Mr. Stanley removed the left
lower limb above the knee for disease of the knee-joint.
He was the subject of chronic phthisis at the time of the
operation ; and the question was carefully discussed
whether amputation should be performed on him. It
was decided on ; and though he has been phthisical ever
since, and always very poor, yet he is still well enough
to pursue some quiet occupation. I can hardly think
he would have been doing so at this time, if he had had
to bear at once the burdens of both tubercular lungs and
a painful knee-joint.
There is a risk, common to the progressive phthisis and
the suspended alike, that by long-continued confinement to
one atmosphere, such as must happen after the excision of a
I
38 RISKS OF OPERATIONS.
joint, you may put the patient into that state of quiet
gradual impairment of heahh which is so terribly
favourable to the progress of tubercular disease. Among
all these risks you must make the best choice you can.
And there is one point in relation to them about which it
will be well to speak. Patients with long-standing stru-
mous disease often look phthisical, whether they have
tubercular disease or not. And, occasionally, you find one
with cough and rapid breathing, and many other symp-
toms so like those of phthisis, that nothing but the most
exact stethoscopic examination can persuade you that the
lungs are in their structm^es sound ; yet all these symp-
toms may be removed by the removal of the diseased
part. Some years ago, I had a young lady for a patient
with strumous disease of the knee-joint, of six or seven,
years' duration ; and for many weeks she had had irrit-
able cough at night, quick pulse, and rapid breathing,
and all the signs which on a superficial examination
might have led to the belief that she had phthisis. Yet
no tubercular disease of the lungs could be detected, and
I removed her limb above the knee. Up to the night
before the operation she had been restless with cough-
ing. After the operation it was doubtful whether she
ever coughed again. ^
* The question of operating for fistula in phthisical patients is fully dis-
cussed in Curlin*,'-, Diseases of the Itectum, 1863, p. 102; IT. Smith,
Holmes' 8 System of Swf/eiy, '2nd Ed., Vol. iv. p. 832 ; Allin<.»-hain, Diseases of
the Redum, 1871, p. 39 ; l^richsen, Science and Art of Sajyeri/. Va], 5, Vol. ii.
p. •'>1.'>. The general cunclusion from their statements is similar to that of
the lecture.
39
LECTUEE III.
Cektain" diseases of the kidneys increase the risks of
operations more, I think, than do the equally chronic
diseases of any other internal organ. And the chief of
these diseases are, first, those which are associated with
the constant existence of albumen, or with the frequent
or constant presence of pus, in the urine. In tl^e first
group, those of which we commonly speak as cases of
albuminuria, the risks of erysipelas and of pyasmia seem
to reach their climax. Not that I know this from having
frequently operated on patients thus diseased. We are
too cautious for this ; and, as you know, no patient with
any chronic ailment goes from my wards into the operat-
ing-theatre without a previous examination of the urine.
Bat you may learn it from the frequency with which
accidents, such as scalp-wounds, compound fractures,
and the like prove fatal in those who are subjects of
albuminuria. All the dangers of which you are taug]:it
in medical lectures as to the tendency of albuminuria to
generate pericarditis, pleurisy, and other internal inflam-
mations, are proved emphatically when the patient's
general health is disturbed by the consequences of injury,
whether accidental or by design. I do not know by how
many times the risks of a given operation are increased in
any patient who has albuminuria, but I do know that you
40 J^ISJ^S OF OPERATIONS
will find it a safe rule never to perform any operation
without an acquaintance with the manner in which the
patient's kidneys discharge their function ; and never to
perform one, except under something like compulsion, on
a • patient whose urine is constantly albuminous. I do
not say that you should never operate on such a patient,
for the exigencies of the local disease may justify you, as
they may justify you in operating in the advanced
phthisis ; but be clear that you operate against heavy
odds ; for even if tlie patient do not die with erysipelas, or
pysemia, or some other form of diseased blood, he will be
apt to linger with a wound half-healed, till at last he
dies of his renal disease just as if you had done nothing.
You saw a patient of mine, in whom we were cer-
tain of the existence of advanced granular disease of the
kidneys, with albuminous urine, die last year. A poor
woman who, ten years before, had one limb amputated
below the knee for chronic ulcer of the leg, came with
the remaining limb so badly ulcerated, and so hindering
her poor means of living, that she begged me to remove
this leg too. She had recovered from one amputation,
and had such comfort in consequence of it that she
begged me to give her the possible advantages of
anotlier, at whatever risk. After many vain attempts
to improve or palliate her condition, I removed the
limb ; and then you saw how, week after week, the
stump remained unhealed, and how, tliough she was re-
lieved of pain, and remained hopeful to the last, she be-
came more and more feeble and oedematous, and died, just
as she would have died if she had retained her limb — in
greater comfort indeed, but not a day later.
IN DISEASE OF THE KIDNEYS, AND BLADDER. 41
The suppurative disease of the kidneys which is of
most importance in operations, is that which many call
pyelitis — a suppurative inflammation of the lining mem-
brane of the pelvis, calyces, and larger excretory ducts of
the kidneys, extending to and widely disorganising their
tubular structure. Its chief interest is in its relation
to lithotomy and lithotrity and the various operations
for urethral stricture. In all of these it is a complication
of the gravest kind ; and in all of them you must inquire
carefully, not only into the mere existence of pus in
the urine, but as to its quantity and probable source.
If you can convince yourselves that it comes from
one or both kidneys, you must regard the case,
whatever be its nature, as one of more than ordinary
gravity. Pus from the bladder is a comparatively un-
important thing ; it means only a local mischief which
local treatment may, perhaps, cure ; but pus from the
kidneys may, and commonly does, mean that these,
which, in reference to recovery from operations, are, I
believe, the most important excretory organs of the
economy, are inadequate for their work. If pus is coming
from them, they will certainly not be excreting their due
quantity of the proper constituents of the urine ; and, at
any disturbance, the patient will be apt to become the
subject of the so called urinary fever, in which the
phenomena of ordinary traumatic fever are seriously
complicated by retention of the materials of the urine in
the blood. Now, in reference to lithotomy and lithotrity,
the evidences of suppurating kidneys may be such as to
induce you to advise the patient rather to submit to his
disease than to risk an almost inevitably fatal operation.
42 J^/SKS OF OPERATIONS.
But supposing the case to be less grave than this, and
that the removal of the stone is advisable even in
the face of a large risk, you must choose betAveen
lithotomy and lithotrity. The choice is a very diffi-
cult one, and scarcely admits of general rules. If the
stone be such an one as can be got rid of with
one or two crushings, I would prefer lithotrity. If
it would require twice as many or more crushings,
I believe lithotomy would be better. If the bladder
be sound, or nearly sound, so much the better for
lithotrity ; if it be unsound, like the kidneys, lithotomy
will be the safer operation, and may even be in-
directly beneficial by providing, for the time, a ready
discharge of the pus through the lower part of the
bladder.
For the various operations for stricture, in cases
complicated with this condition of the kidneys, there
is one very plain and obvious rule : being unfit for
cutting, these patients should be treated with the
gentlest possible means of other kinds. And, by the
way, let me advise you, in every such case, to satisfy
yourselves, before proceeding to mechanical treatment,
that medicinal treatment is really insufficient. Every
year teaches me more and more plainly that a very
lar<''e number of cases of stricture of the urethra are
really not dependent on any fixed condition of the
urethra, but upon mere swelling of its mucous mem-
brane— upon just sucli swelling as, with chronic catarrh,
narrows or shuts up one or both nostrils. Manual sur-
gery should find little or nothing to do in cases such
as these.
CA THE TERISM. 43
It may seem to some of you absurd to include catlie-
terism among the surgical operations in which the general
condition of the patient's health can have any material
influence. And yet I will not omit it, for it is a much
more important affair than in the beginning of your pro-
fessional studies you are likely to suppose. None of the
minor operations of surgery is so apt to be followed by
serious mischief. Very many patients with stricture of/
the urethra are unsound, or, if not unsound, yet with un-
certain and capricious health — dyspeptic, or gouty, or
with kidneys which, if not diseased, have been very often
disturbed in their action, and are, therefore, unsuited for
any constitutional disturbance. You should, accordingly,
be at the least very cautious in the use of catheters upon
persons of whose general health you know nothing, and
upon those who are unaccustomed to their use, and upon
those who come to you with strictures which are only
somewhat worse than usual by reason of some passing
disturbance of their health. And the rules of caution
may be twofold stronger when you have to deal with old
persons ; for I am convinced that a first catheterism has
been the first step towards death in many old men. You
must therefore be on your watch for the general signs of
health in patients on whom you must pass catheters, just
as in those on whom you would perform any cutting
operation. Look upon first catheterism as involving a
risk of troubles about as great as that of amputation of
a finger or a toe, or the removal of a small tumour, in a
person of the same age. A small risk, you may say ; but
it is not less than two or three per cent. ; and the cala-
mity of death, when it does happen, is aggravated a
44 I^/SKS OF OPERATIONS
hundredfold by its coming without warning, and from
what seems to all an inadequate cause.
By the way, let me tell you of a symptom which must
make you especially cautious if you have to catheterise
elderly or old men. If they are passing large quantities
of pale urine of very low specific gravity, whether con-
taining a trace of albumen or not, they will be in
danger from even the most gentle catheterism. For this
condition of the urine is often due to some advanced
defect of action in the kidneys, and catheterism will be
followed by inflammation of the bladder, and the so-called
urinary fever, and death will hardly be escaped.
As to diseases of the nervous system in patients who
are to be the subjects of operations, I need hardly say
that neither I nor any one can have considerable experi-
ence in relation to the influence of organic disease of
cither the brain or spinal marrow. We do not often
operate upon mad people, or paralytics ; and what I can
tell you is rather in relation to the influence of minor or
paroxysmal disorders of the nervous system.
The healthiest nervous system, in so far as it may be
judged of by the mind, is that in which a patient faces an
operation quietly, and with a courage which is not too
demonstrative. Cases are told, and some of them, pro-
l)ably, are true, and I have seen confirmations of them,
which woukl make it very probable that an abiding
gloom, or fear of death, or a forctelhng of death, or an
utter indifference to the result of the operation, are very
l)ad states. ]kit, after all, your estimate of the risks on
any such grounds as these must be a vague one. A better
sign is the capacity for sleep. If a patient can always
IN NERVOUS PERSONS: IN THE INSANE. 45
sleep long at a spin, that is a good patient. In one of the
most perilous operations for hernia with which I have
had to do, a case in which the hernia had been reduced
en bloc, and in which its return was effected with con-
siderable force and disturbance of parts, I believe the
patient owed his recovery more to his capacity for sleep
than to anything else. He was a young bargeman, dull-
witted and over- worked ; and in his ordinary life sleeping
whenever he was neither working nor feeding. Shortly
after the operation, he went to sleep ; and he slept
sixteen hours out of the first twenty-four, and in a
scarcely less proportion of his time for two or three days
afterwards ; and he recovered, although he had acute
peritonitis, for which I thought it necessary to put on
nearly a hundred leeches.
You may have to operate upon insane persons, and in
them you will be able to confirm the rule that is estab-
lished by the observation of all who attend them, that
they bear pain and severe local injuries with less distress
or ill consequences than the sane do ; but that they
recover with great difiiculty from chronic ailments.
Moreover, if you operate upon them you must take all
the risks of their interrupting their own recovery by
some insane whim or violence. I lost a patient after an
operation for hernia through her first insanely refusing all
food, and then insanely drinking enormous quantities of
fluid, which brought on sickness.^
Delirium tremens is an indication of a complexity of
risks. The' man who has brought himself to this con-
dition by hard drinking, unless indeed it be the result of
1 See Note V.
46 I^ISKS OF OPERATIONS.
extreme but rare intemperance, is in all the risks tliat
belong to drunkards, and besides these, his restlessness
will constantly increase the local danger of his wound.
I would, therefore, never perform any large operation,
except under compulsion, on a patient already the subject
of delirium tremens. I can hardly imagine the serious
accident of which the risk in such a patient would not be
increased by any serious operation. But you are more
likely to have to do with these patients when they become
delirious after operations. In this case you must do the
best you can for them, according to the general methods
of treating the disease ; of w^hich general methods I will
only say that, the less you rely upon opium and the more
upon good food, the less you subject them to absolute
restraint and the more to quiet nursing, the better will
be your chance of success.
Very rarely, patients become insane after operations
or accidental injuries, just as women do after parturition.
I long thought that the absence of anything like a parallel
to puerperal mania was one of the few points in which the
consequences of operations differ widely from those of
parturition, w^ith which, in many important characters,
you know that they closely agree. But within the last
few years I have seen cases in which the parallel seemed
/ to be completed. In one such case, within two days
after a compound fracture of the leg, an elderly woman,
who had never before shown signs of insanity, became
maniacal with merriment and sleeplessness, and so died
exhausted, the broken limb having apparently little in-
fluence u[)on lier state. In another case of compound
fracture the patient became insane within a few days of
INTERCURRENT INSANITY: ANEMIA. 47
the injury, and remained so till nearly the time of her
complete recovery. I have known a case in which reli-
gious mania ensued quickly after lithotomy ; another in
which fatal melancholia followed an otherwise successful
lithotrity ; and another in which fatal acute mania fol-
lowed erysipelas after a minor operation. Such events,
however, are so rare that they need in no degree interfere
with the judgment which you would form as to the pro-
priety of any operation. Only under the strongest proba-
bility of insanity ensuing after it, would the fear justify
one in dissuading a patient from that which might be
necessary for his health or life.
Of the nervous, the highly neuralgic, the over-sensi- I s/^
live, and those with over-active brains and spinal cords, '
I have already spoken. *
To conclude these questions of the influence of diseases
of organs and systems on the results of operations, let me
say somewhat of certain conditions of the blood to which
I have not yet referred : chiefly of ansemia. It is not a
bad condition in which to operate, unless it be, that, if
anaemic patients fall into the risks of erysipelas or the like
casualties, they are less likely to get out of them. Except
for these risks, anaemic patients — who are best repre-
sented, perhaps, by those who have had large losses of
blood from the uterus, or infrequent secondary haemorrhage
from wounded arteries — pass well through the dangers of
operations. Their wounds heal slowly, but soundly ; and
they recover their health at least as well as any other anse-
mic patients do. I say expressly, ^ secondary haemorrhage
from wounded arteries.' If you are dealing with a
patient anaimic through secondary haemorrhage late after
48 J^/S/sTS OF OPERATIONS
an amputation, you must not forget that the secondary
haemorrhage itself imphes some defect of the heahng
process, which may be due to some general unsoundness.
It is a general rule, and I dare say a prudent one,
not to operate during menstruation. The best time
is believed to be within a few days after a menstrual
period. I do not know the grounds upon which this
belief rests ; but they are just of that kind which it is
at least prudent to respect, unless in cases of real
necessity. Still, I have seen no mischief occur in the
few cases in which, by oversight or necessity, I have
operated either directly before or during a menstrual
period. The cases have not been many, but in none of
them has any mischief ensued. Not infrequently the
occurrence of the first menstruation after an operation is
attended with much more discomfort than the patient has
commonly endured ; and in those who are subject to
menstrual distress, symptoms of general disturbance,
enough to excite alarm, may be associated with it. The
probabihty of the advent of menstruation is therefore
always to be considered in the case of anomalous symp-
toms after operations. And it may be well to mention
that, after operations on the genital organs and the
breasts, it is by no means rare for the next menstruation
to occur some days earlier than, in the ordinary course
of events, it would have done.
As witli menstruation, so, much more, during preg-
nancy, you would not willingly operate. And yet, with
the exception of tlie danger of producing abortion, I
know no facts that would imply a greater than the
average risk ; and if we may suppose a similarity be-
DURING MENSTRUATION, AND SUCKLING. 49
tween patients pregnant and those recently parturient,
we may believe them comparatively safe. The repair of
a rent perineum is as good an example of the healing
of a bruised and lacerated wound as you could well find.
And, altogether, the recovery of the enormous majority
of parturient women from a condition which, in many
respects, is like that which follows surgical operations,
may prove them very safe subjects. However, on this
point pure surgical experience neither is nor can be large.
We can only say that, while, on the one hand, it would
be mere recklessness to operate on such patients without
good cause, yet if good cause for operating exists, they
may be treated very hopefully.
When women are suckling they will bear operations
with no more than the common risk that miofht attach to
o
persons who may be in comparatively feeble health. The
mere presence of lactation seems to have no bearing on
the matter. But an exception must be made, I believe,
for operations on the breast. I never did one and, if I
can help it, never will ; and to this conclusion I should
have come even if I had not read a case of fatal haemor-
rhage from a breast cut widely into during active lacta-
tion.
Now, I hardly need tell you that what I have said is
a mere sketch of a very large subject — far too large for
me to complete. I would have you all work hard at it ;
and a help to your doing so will be to change the usual
mode of recording cases in which operations are per-
formed. Usually, the account of the operation is nearly
the end of the case, and is followed by a bare statement
that the patient did well or ill. But, in most instances,
E
^ ?
50 RISKS OF OPERATIONS.
after an operation an entirely new case begins ; a case,
not of disease, but of injury. Accordingly, you should
begin an entirely new record ; and day by day you
should set down all the events that follow the operation.
Most of what I have told you is founded on the reports of
a large number of cases which I have thus watched and
recorded in a tabular form.
By this method of study you may gain knowledge of
the highest importance in your practice. Not only may
you improve yourselves in the treatment of patients after
operations, but, by seeing how those Avith different con-
stitutions or local diseases are differently affected by
the operations, you may learn how to prepare them.
Even from what I have said in these lectures you may
see that there can be no one sufficient method of prepa-
ratory treatment ; no single rule of purging or crannning,
of starving or intemperance. The only single rule is, to
put each patient into the best possible health for bearing
injuries ; and this, as I have said, is not always the
best health for hard Avork or pleasure. If I may venture
on a large general statement upon such a point, I will say
that each man's capacity for bearing a surgical operation
may be best measured by the power of his excretory
organs in the circumstances in wliich the operation will
place liim. But the means of regulating this power, or
of increasing it, nuist be as various as are the patients
themselves. You nuist study the whole matter very
carefully; and I liope I sliall not luive wasted either
your time or my own if I shall have enabled you to
start from the point which, after many years' work, I have
j-eached.
51
THE CALAMITIES OF SURGERY.
Two cases have occurred during the last week, which
lead me to speak to you about what may be called the
Calamities of Surgery, a subject of great interest, which
you had better begin to study in early life ; for the study
of it, if deferred to later life, only leads to reflections
which are useless and distressing.
Last Friday a patient died under the influence of
chloroform. It was given with all customary care, and
there is nothing in all the circumstances to which we can
refer that would imply that any thing was left undone
that ought to have been done, or anything done that
should not have been done. In the morning I had ad-
vised the chloroform for this patient, whose hand had to
be put straight in order to avert the deformity that was
being occasioned by disease of the wrist-joint. In the
afternoon my house surgeon and a dresser were giving
it, the pulse suddenly failed, and the patient sank and
died. The friends would not allow a post-mortem
examination, so the case aflbrds us no useful information.
But the fact that I want you to keep in mind is that not-
withstanding all care, and all good intention, surgery
E 2
52 777^ CALAMITIES OF SURGERY. ■
shortened to a few minutes this woman's hfe that miofht
have lasted many years. At tlie very worst she would
have gone about for the remainder of her life with a
crippled hand ; but she might have lived to a good old
age. She died ; and died without any warning of her
danger.
This is one of the calamities of surgery. It is one of
the many cases that lead one to wish that something
mio'ht be discovered or invented which should combine
what, I believe, was the greater safety of sulphuric ether,
the first and original anaesthetic, with what is the far
greater convenience and facility of administration of
chloroform. But till that substance is discovered we
shall liave to proceed in surgery with uncertainty ; or
rather with the certainty, that occasionally, we cannot
tell when, some one whose life we are trying to pro-
long or ease will die, and die by the means that we use
to save him from pain.^
The other case was that of a man on whom I
operated for the removal of the head of the humerus. He
came, you will remember, with his right arm almost com-
pletely useless and often very painful because of an unre-
duced dislocation at the shoulder. The dislocation had
been unreduced for, I think, eighteen months, and there
was no hope of re])lacing the bone by any ordinary
means. The man himself was urgent that the arm
should be made in some measure more useful and less
painful than he now found it, and accordingly we decided
' For the last two years I have used only sulphuric ether or, for short
operations, nitrous oxyde gas or ether-spray. The inconveniences of the
ether are lenxMlied by Mr. Clover's method of makiujj the patients insen-
sible with nitrous oxyde and then givino^ the ether.
THE CALAMITIES OF SURGERY, 53
on what seemed to be the only thing for his rehef, ex-
cision of the head of the humerus, which by pressure on
the brachial plexus appeared to cause the pain. I did
that operation ; and a few days after it, pyaemia set-in,
and in a few weeks the man died. There were many
circumstances in this case to diminish the rebuke that
one was bound to inflict upon one's self. The man was
exceedingly urgent for the operation, and urgent rather
against one's own suggestions ; and, which was worse,
after the operation, out of sheer wilfulness and obstinacy,
he refused for a time all careful nursing, and absolutely
refused his food, and so diminished greatly his chance
of recovery. Nevertheless, the fact remains, that but for
the operation this man might have lived for many years ;
he would have lived with an only partially useful right
arm, but he would have lived, and been able to work
and would have done some good for himself and others ;
but because of the operation instead of living many years
he died in three weeks.
Cases such as these ought to be very honestly con-
sidered by us all ; for I venture to say that there is no
surgeon in large practice, no surgeon to a large hospital,
who has not once or more in the course of his life
shortened patients' lives when he was making attempts
either to prolong them or to make them happier. And
this, you will observe, is not merely the case with capital
operations. When a patient submits to a large operation,
it is always for the remedy of something that will render
his life either very miserable or very short ; and to es-
cape so great distress, it is quite fair that a man should
run great risk of his life. But these calamities occur
♦e3
54 THE CALAMITIES OF SURGERY.
however rarely, in comparatively trivial cases ; when the
operation is not done for any consideration of prolonging
life, but, it may be, of making hfe somewhat happier, or
somewhat more useful, as in the amputation of a finger,
the tapping of an ovarian cyst, the tapping of a hydro-
cele, the division of a cervix uteri, the hgature of a pile,
the division of a fistula, the removal of a small tumour
from the face or scalp. I have known deaths from all
of these, and if you were to go over the whole list of
so-called minor operations, you would find that every
surgeon of much experience has either had in his own
practice, or known in that of others, one or more cases
of each that have proved fatal. If any man will remove
with the knife, in a hundred instances, cysts from the
scalp, I will venture to say that he will have one or two
deaths. If any man will take in succession an equal
number of cases of ligature of haemorrhoids, the pro-
babihty is that he will have one or two deaths. The
puncture of an ovarian cyst, tapping it for the first time,
is fatal in three or four cases in every hundred. It is
not necessary, however, that I should recount all these
operations to estimate, what indeed it would be quite
beyond my power to estimate, the average mortality of
each ; that wliich is most important for you to under-
stand is that, without very great care, you wiU certainly
lose patients after minor operations, and be severely
])lamed for the loss.
Moreover, these deaths, though they are the worst,
are not the only events that ought to be reckoned as
THE CALAMITIES OF SURGERY. 55
calamities of surgery. We ought to add to the hst all
those cases in which operations for comparatively slight
diseases are followed by very serious illness, or by perma-
nent damage greater than the disease, as when the
removal of a finger leads to cellular inflammation of the
hand and permanent stiffness of some part of it, or when
after circumcision sloughing ensues, or after the
removal of a scalp-cyst dangerous erysipelas.
All these things might be matters of no more than
passing regret to us if they were altogether inevitable ; if
we could say that everything of this kind is purely acci-
dental ; a thing which no foresight could have averted ;
which came upon us out of circumstances over which we
had no control whatever. But the truth must be fairly
confessed ; that these are not always accidents ; and that
often, when the calamity has occurred and we look back
on the events that preceded it, we can find that the
disaster was the result of some oversight, or of some
carelessness, or want of judgment or of skill. Do not let
me seem to imply that there are no cases of this class which
we may call purely accidental. Calamities in surgery
may come of things which nothing far short of omnisci-
ence could have detected beforehand. A fever may fall
upon a man after an operation ; for even minor operations
put persons into conditions in which they are more
susceptible of the infection of fevers than they were
before.^ We cannot guard against that. Tetanus may
ensue after a minor operation ; we have no power to
avert that, or even, in the smallest degree, to apprehend
^ See Essay on Scarlet Fever after Operations.
56 THE CALAMITIES OF SURGERY.
its approach. These and other causes of the kind and,
still more, the negligence and recklessness of patients,
would diminish by a considerable number the list of cala-
mities for which we may seem blameworthy ; but there
would still remain more than facts enough to serve you
for a warning that you can only by exceeding watch-
fulness avert the calamities that are apt to occur through a
comparative want of care, or of skill, or of judgment.
Let me tell you now some of the cases that I have
known. They were happily not all in my own practice,
and I need not say which Avere and which were not.
A man had albuminuria, and he had a small cyst on
the scalp which it was tliought advisable to remove. It was
removed, and erysipelas set-in and of that he died. And
then it was found that he had albuminuria, a condition
which made him so liable to erysipelas, or to pyaemia,
or to some form of blood-poisoning, that if it had been
ascertained beforehand no prudent surgeon would have
thought of operating.
Another person was a drunkard, on the sly, and yet
not so much on the sly, but that it was well known to
liis more intimate friends. His habits were not asked-
after, and one of his fingers Avas removed because joint-
disease had spoiled it. He died in a week or ten days
witli spreading celhdar inflanmiation, such as was far from
unlikely to occur in an hnbitual drunkard.
Anotlicr patient was very liable to large bleedings
from small incisions. Tliis Avas not asked-after ; some
small incision Avas made and lie died tlirouuh the feeble-
ne^s consequent on liiemorrhages.
THE CALAMITIES OF SURGERY. 57
Another had a small tumour of the face, and was so
feeble in his ordinary condition of health, that more care
would certainly have suggested that he would not bear
even a slight shock and small amount of haemorrhage.
He sank after the operation.
In another case, sutures were, by plain mistake, put
tlirough the aponeurosis of the external oblique muscle
after ligature of the external iliac artery. Infiltration
of the first products of the inflammation following the
wound ensued ; the suppuration spread far and wide, and
the patient died through its effects in a few days.
An old man, with an irritable bladder, and who was
passing a large quantity of urine of low specific gravity,
came complaining of certain symptoms of stone. He was
carelessly and rather roughly sounded for stone, went
home, had a shivering fit and acute inflammation of his
bladder, and died in ten days. The sounding would not
have been done if due care had been taken to examine
previously the condition of his urine.
Another man in a similar condition had an inflamed
urethra. He was catheterised, acute inflammation of the
urethra followed, and then retention of urine, acute in-
flammation of the bladder, and through that, death He
ought not to have been catheterised until after some few A ^^"
days of rest. /
And so I might still tell of cases operated on, in
which, after the event, it was discovered that more care-
ful previous consideration of the case, or more skill, or
more ilfter-care would have saved a life that was lost, or
would have averted some dangerous and painful illness
or some permanent damage. It does rest upon us all
58 THE CALAMITIES OF SURGERY,
to consider tliese things very carefully. We are all the
more bound to consider them honestly and, if need be,
with self-reproach, because these calamities are not such
as the public can judge of. They are not instances of
those gross negligences and carelessnesses which can be
punished legally and openly. Nor is it indeed at all
advisable or desirable that the public should know of
these cases. They could not help us, and they would
form very wrong judgments about them. Indeed, in
such cases the public just as often judge wrongly as
rightly, and accord credit where discredit is due. I
remember once, when assistant-surgeon to the hospital,
I divided a prepuce that was acutely inflamed ; an
operation that ought not to have been done. The
patient went home and bled furiously from the vessels
of the foreskin ; and then followed acute inflammation
of the whole integument of the penis and of the scrotum,
and sloughing extended to his groin. He was admitted
into the hospital, and passed tlirough great peril of his
life. He did not die, but he was very nearly doing so,
and he was long ill and in misery. Four weeks after, a
man came to the out-patients' room to return thanks for
the help tliat I had given him. I did not know him at
first, and I said, ' Wliat did I do for you ? '
' Oil sir,' he said, ' if it had not been for that cut you
made, I should have died.'
That was his firm impression ; tliat if I liad not made
tlie incision, which was the sole source of his danger, he
must liave died of something very terrible which tliat
incision just prevented.
Another case bearing on the same point, of the mis-
THE CALAMITIES OF SURGERY. 59
taken judgment of the public, was this ; of which,
however, I only know by hearsay. Many years ago, a
distinguished surgeon at one of the London hospitals,
admitted, as one of the casualties of the week, a gentle-
man with a strangulated inguinal hernia. With great
carelessness this surgeon cut right into the intestine, in
the middle of the hernia. Faeces flowed out and all the
miseries followed of a piece of intestine projecting from
the wound and discharging its contents. The case excited
considerable attention ; it was always carefully watched
and at last the patient recovered. His impression of
what had happened was that he had, by this very incision
into his bowel, escaped some dreadful calamity ; and that
nothing but the most extreme skill could have either
made the incision into the bowel or recovered him after
it ; and he presented the surgeon who had done this for
him with a very handsome gold snuff-box. The surgeon
proved himself quite worthy of the gift, for he used to
show this gold snuff-box to prove the gratitude which
the officers of his hospital were in the habit of receivins^
from the patients upon whom they conferred the great
benefits of charity and skill.
We must then, I repeat, blame ourselves for these
things and scrupulously watch ourselves ; for the more
the sufferers from these errors or defects of ours are help-
less, the more it rests upon our consciences to stand in
their place and help them. I will therefore take this
occasion for putting before you some rules which you
had better follow ; rules by which you may be able to
avert from yourselves the regrets of these calamities
of surgery.
6a THE CALAMITIES OF SURGERY.
"First of all, the consideration that you are liable to
these calamities should be an incentive to the most
earnest and continual study of your profession, that you
may avert all avoidable ignorance ; and to constant dis-
cipline in watchfulness, that you may overlook nothing
that can contribute to a patient's welfare.
And you should study very carefully all of what are
called the minor parts of your profession. Minor they
may be with regard to each instance in which they have
to be practised ; but they become major if you multiply
those instances together. I refer chiefly to the necessity
of cultivating skill in dressing wounds, in the com-
pletion of operations, in the looking to all the seemingly
little things that, after an operation, minister not only to
a patient's comfort, but to his w^elfare. Among the cases
that I have to regret is one in which a patient of mine
died from a piece of plaster being put on in the wrong
direction. A young man liad a tumour removed from
deep in the back of his thigh ; and at the end of the
operation, I know not whether by myself or some one
else, a broad strip of plaster was put round the thigh,
completely encircling it, and over that, for some further
means of security, a bandage. Next day the limb was
swollen, but apparently not much more than it might
have been swollen, from ordinary inflammation follow-
ing an operation. But, the day. after, the limb was
swollen much more ; and the day after that, there was
acute inflammation of all the cellular tissue about the
wound ; and then came hacmorrliage ; and then the man
sank and died. The sole cause of his death was the strip
of plaster wliich was put round his Umb and not removed
THE CALAMITIES OF SURGERY. 6i
for two days. From that time to this, I think no one
has ever seen me put a strip of plaster round a hmb, un-
less spirally. Small as such a thing may seem in the art
of dressing, it cost that man his life. I tell the case that I
may in some degree atone for the fault by hindering you
from incurring the same risk. Attend then carefully to
what are called the minor things of surgery ; not merely
to skill in operations, large or small ; learn the habit of
entering completely and fully into everything that may
minister to the safety and comfort of the patient.
Next, let the liability to these calamities move you
never to decide upon an operation except in consideration
of the patient's interests alone. Let no thought of your
own interest, or of your own reputation, have any place
in the consideration of what is to be done for this or for
that man. If an operation is not purely and wholly for
the good of a patient, it should on no consideration what-
ever be done. When an operation is decided on, you
may add a deske for your own reputation to the motives
that will induce you to do the best you possibly can
for the patient ; but this, which is a very fair motive
for the careful performance of an operation, is a very foul
one in determining whether an operation should be done
or not. * I can imagine nothing that would add more to
the remorse of a man who had fallen into one of these
calamities of surgery, than the recollection that he pro-
^ceeded to the operation with some consideration of his
own interest or of his own reputation.
Next, never decide upon an operation, even of a
trivial kind, without first examining the patient as to the
risks of his life. You should examine him with at least
62 THE CALAMITIES OF SURGERY
as much care as you would for a life-insurance. It is
surely at least as important that a man should not die, or
suffer serious damage, after an operation, as that his life
should be safely insured for a few hundred pounds. Be-
fore any man's life is insured, he undergoes an inspec-
tion of at least one medical man, and possibly of a whole
board of directors. At least an equal amount of inspec-
tion ought to be made for every man who is to be sub-
mitted to an operation : and this involves a general fair
consideration of what the man's present health is, how
he looks, what is his pulse and his breathing, what he is
in respect of temperance, what of exercise ; whether he
has ever had any serious illness, whether he is liable to
minor ilhiesses : in short, in regard to what this sort of
examination should be, you may take for guidance the
papers which insurance-offices give to any one who pro-
poses to insure his life. They ask a variety of questions
which enable you, on tlie whole, to judge very fairly
what are the chances of a man livino^ out to the full
length of life, and all those chances should be considered
before even a minor operation, which is not of urgency,
should be done. And, in this respect, do not too soon
take examples from your seniors, myself included, as to
the manner in which we judge of a patient's fitness for
an operation ; because, what we can do in a comparatively
sliort examination, you cannot do. The ability to see
quickly what is the general condition and character of
a patient's liealth is the result of very long-continued
study. It would be; hard to tell you what are the
successive stages of knowledge through wliich any man
of experience passes before he comes to say, almost at a
THE CALAMITIES OF SURGERY. 63
glance, what is the general health of a person presented
to him ; but the ability to do this is the result of several
stages of knowledge, each of which has been carefully
passed-through. It is the same kind of knowledge which
you see every successful man exercising in his own craft ;
one of those special skills, only to be acquired by careful
and long-continued study ; and till, by experience, you
have attained such skill as to be able to decide questions
of this kind in surgery quickly, you must compel your-
selves to decide them slowly, and w^ith a very careful
study of each case that is presented to you.
If I w^ere to count the number of preventible calami-
ties in surgery that I have known, I should find the
majority of them due to the oversight of personal defects
in the patients operated on ; defects in the habits, the
constitution, or the previous diseases, which ought to
have been ascertained before the risk of the operation
was incurred.
But, again, when you have decided on an operation,
never make light of it. Never talk to the patient flippantly
about its being what is called ' nothing ; ' a mere snip, a
mere cut, a mere this or that. It never is so to the patient's
own feelings ; to patients an operation is always an im-
portant matter ; and they are rather aggrieved than
pleased on being told that it is ' nothing.' You need not
alarm a patient ; you may say that the risk of an operation
is not greater than that which he would incur for much
less sufficient motives. Most people, for pleasure's sake,
incur larger risks than they would in a minor operation.
They travel by express trains and they climb Alps ; they
hunt and shoot ; and for no adequate motive they run
/
64 THE CALAMITIES OF SURGERY.
across the crowded London streets ; and for mere pleasure
they expose themselves to dangers of fatigue and cold
and indigestion and other risks of illness. So you may
fairly guard yourselves, and give your patients a just
measure of warning, by saying that the risk of a pro-
posed operation is not greater than the risk of this or
that thing which they wilhngly do for amusement. But,
unless you are prepared to say that the risk is not
o^reater than oui>'ht .to be incurred for the good which
may be expected to foUow, you ought not to do the
operation at all.
As to the amount of good which is to follow an
operation, the surgeon alone can in most cases estimate it.
In most cases, therefore, we must take the whole respon-
sibility of operations, for it is only on our statements that
patients can rely in judging whether they should submit
or not ; and most of them, even when they have our
statements before them, are quite incapable of clearly and
soundly judging. But there is a class of operations,
in what I have called decorative surgery, in which we
may justly put upon patients a much larger share of the
responsibility than tliey ought to bear when the question
is one of life or death. When people want, not to be
cured of absolute deformity which liinders their success
or comfort in life, but to have this or that done of which
it does not matter whether it is done or not except for
some personal vanity, let them understand tluit tlie opera-
tion is not altogether free from risk, and then let thean
take the wliole responsibility of the matter.
Supposing, now, an operation to be decided on, there
THE CALAMITIES OF SURGERY. 65
are some rules to be observed with regard to its per-
formance, which may be useful in averting calamities.
First, don't be too ready to operate in your own
houses or in your own rooms. It is a thing too com-
monly done and always involves a risk which should
not be incurred without need. Mr. Thomas Blizard, who
was in his time one of the most distinguished surgeons in
London, when he began practice in the city,, was once
consulted at his house by a merchant of great wealth and
influence, who thought he would patronise the young
man ; for he knew his family. He called on Mr. Blizard
one morning, showed him a cyst on his back, and asked
him to remove it ; and he removed it then and there.
The merchant went away, caught cold, had erysipelas
and died in ten days. I do not know what amount of
unhappiness the case excited at the time ; but I know
that Mr. Blizard told it in after life with the greatest
regret ; and that, as a measurable amount of part of the
calamity to himself, his income fell 50 per cent, after that
year and was not quickly recovered. It rose to a very
large amount before he retired, but 50 per cent, for a year
was the amount of damage which he sustained by not ob
serving the rule, of not operating in your own rooms
without a real need of doing so. You may do an operation
there, with all dexterity and care ; but you do not know
what the patient will do afterwards. Especially, let me
advise you not to sound a patient for the first time, or to
pass a catheter in a man of questionable general health
for the first time, in your own room.
Again, do not operate upon even small inflamed parts. /
F
66 THE CALAMITIES OF SURGERY.
The mention of that last case of an encysted tumour re-
minds me of the frequency with which patients come to
you for similar operations, to be done because the parts
are giving them more trouble than they used. A man
will bear a little tumour, or a small cyst, or a small pile,
so long as it is not inflamed ; but when it inflames it
teases him, and he asks to have it removed with all speed.
Don't do it. The risks of operating on an inflamed part
are manifold, and much greater than the risks of operating
u})on one that is quiet. A man came to me in the out-
patients' room, while I was assistant-surgeon, with a cyst
on the front of his abdomen, acutely inflamed. I removed
it then and there. Three or four days afterwards he was
admitted with inflammation of the cellular tissue and infil-
tration of putrid matter under the skin ; and that was
followed by phlebitis, and that by pyaemia, and that by
death. The man was dead in three or four weeks after a
very small operation for the removal of a cyst from the
front of the abdomen. I operated on an inflamed part ;
I did wrong. If the man liad been ])ut at rest and the
inflanunation cured, tlie cyst might in all probabihty have
been removed without risk.
You may sometimes see in my w^ards bad cases for
whicli I am only indirectly responsible, the ' surgery-
cases ' as they are commonly called, in w]iich fingers are
removed some days after being crushed ; n'moved while
thoy are still inflamed ; and then the patients come into
the hospital will) inflamed liands ; witli cellulitis of the
lumd and of tlie fore-arm. I am bound to say that I
luive not seen any of tliem lately ; but I liave a clear re-
collection of several of them in former years; and of the
THE CALAMITIES OF SURGERY, 67
long pain and illness and disability of the hand which
were caused by the neglect of this rule of caution.
For another rule, always look carefully to the condi-
tion of the room or the house in which your patient is
living ; and set aside, so far as you possibly can, all the
risks that may be thus incurred. Look to the sanitary
arrangements about the man. One of the greatest
annoyances that I have ever had was in the case of a
gentleman whose prepuce I divided for phimosis. Severe
it was, and necessary to be cured. I divided his prepuce,
and no more ; neither put -in a suture, nor did anything
that could disturb the healing of the wound. The cut
was followed by sloughing of the integuments over two-
thirds of the penis and very nearly the whole of the
scrotum. After having done the operation, I found, on
looking-about for what could have caused all this misery,
that the patient, although living in a very good hotel,
had a water-closet in his bedroom. I had looked round
the room, not carelessly, before the operation, to see
whether there was anvthinss; that could bring; him into
mischief, and all had appeared fair. But wliat I had
taken to be a book-case, or some article of furniture of
that kind, was a water-closet, which, with the nastiness
with which some London hotel-keepers provide for tl\e
convenience of their customers, had been put into the bed-
room. And this is not a very uncommon thing, even in
the better class of lodging-houses and hotels in London.
Because every man, in coming to his rooms, likes to have
for cleanliness his own water-closet, or at least to have
one to every suite of rooms, the landlords put one at the
V 2
68 THE CALAMITIES OF SURGERY.
side of a bed-room. Where a wardrobe should stand,
they place a water-closet, and they front it, and make it
look as like a decent piece of furniture as they can. It
was through this scheme that the poor fellow lost the
integument of his penis and scrotum. Look therefore,
I repeat, very carefully to all the sanitary arrangements
that can come within your power, even among tlie better
class of houses and hotels.
Then there comes this rule ; — never do an operation
if you can cure the patient by any reasonable medical
or other means. There are a considerable number of
operations done for cases that should not be operated on
at all ; and these are amongst the very class in which
the mortality of minor operation comes. An instance is
in the case that I just spoke of — of phimosis. It very
frequently requires operation in children, especially if the
orifice of the prepuce be very narrow ; for this materially
impairs the action of the bladder, the patient having to
pass water against a continually too great obstacle. But
among adults, many cases of phimosis can be cured with-
out operation. The prepuce can be gradually and slowly
drawn back ; and by daily drawing the prepuce against
the glans, thus widening its orifice, it may be fully dis-
tended without the need of an operation. Again in cases of
varicocele : patients come to you, begging for cure ; and
nearly all of them are merely nervous, hypochrondriacal,
morbidly-brained people, who are in fright about varico-
celes, which they su])pose to be the causes of impotence and
wasting of tiie testicle. Now, no varicocele, to the best
of my belief, ever did cause impotence or waste a testicle.
v^""^ Cx But the operation for varicocele is not altogether free
THE CALAMITIES OF SURGERY. 69
from danger. A most skilful operator for this disease re-
ported, the other day, a case in which he himself operated
and the patient very nearly lost his life. Once also, I
saw a young man with pysemia following an operation for
varicocele, which had been done very skilfully. Through
this pyaemia he had acute suppurative inflammation of
his right shoulder, his right knee, and his left hip ; and
they were all spoiled, and he very nearly died. I doubt
whether ninety-nine operations for varicocele would do
good enough to balance one such calamity ; for of the
ninety-nine operations the majority would have been quite
unnecessary. Varicocele can, in a vast majority of cases,
be perfectly well managed with a ring, or a truss, or
suspensory bandage and cold water, and the operation
may be wholly dispensed with : the more properly because
varicocele is not a mischievous disease, and has nothing
to do with the impotence or other sexual distresses that
patients ascribe to it.
So also for urethal stricture. Among the operations
that I have known fatal is catheterism, and that not very ,• / / ^
rarely. Don't be catheterising patients for supposed A// /" •^
strictures till you have ascertained that they cannot be
cured medically. Under the general name of stricture of
the urethra are included several conditions which are far
better curable by medicine and diet than by any form
of surgery ; mere transient or chronic swellings of the
mucous membrane of the urethra, to be treated medi-
cinally and treated by diet. Catheterism is nothing but
mischief to them.
Then, for another rule. If a disease can be cured by
a bloodless operation as well as by one with cutting,
70 THE CALAMITIES OF SURGERY.
choose the bloodless. This may be done in many more
instances than 3^011 are apt to think. The cysts of the
scalp have, as I have said, a mortality of some two or
three per cent, at least, and the mortahty in them is of
peculiar distress, since at the outset, except for appearance,
these cysts might be left. They are commonly removed
when, being small, they are sources of but trivial
trouble ; and yet they have this rate of mortality. These
may all be removed with caustic. I do not say that you
never should remove by incision a cyst from a patient's
scalp ; but you never need do so ; and if the patient be
one in whom the risk of an operation is in any degree
greater than the average, you ought to remove the cyst with
caustic.-^
Ligature of hi^morrhoids, again, is an operation some-
times fatal. Sir Benjamin Brodie told me that he had
lost three patients in his life from it. That might be a
very small proportion of the number of patients he
operated on ; but he never ceased to speak of it with
great regret. I have not lost a patient by the operation,
but I have had two in whom it was followed by pyremial
abscess and serious risk of life. Doubtless the ligature
of haemorrhoids may be performed in the vast majority of
healthy persons with complete impunity ; and doubtless
in many it is the best operation for the cure of the
disease, and shoukl be performed. But in many cases,
^ The best method, I think, is to paint the skin over the cyst with the
strongest nitric acid; to paint it thoroughl}', in and in, as if with iodine.
After this small cysts may be left, and the skin and they will shrink and be
cast ofl'like scabs. Large ones, when they begin to separate from the sub-
cutaneous tissue, may be pulled out; and the cavities they leave will heal
"with water-dreseing.
THE CALAMITIES OF SURGERY 71
the cauterising of hEemorrhoicls with nitric acid or the
actual cautery is quite as successful as the ligature ; and
therefore you should not tie piles in any person who
would incur even the least more than the ordinary risk
from the operation unless you are sure that cauterising
will not cure them.
Another class of cases in which I remember some
calamities is that of the little cancerous warts and ulcers
that occur about the face. These may be commonly re-
moved in healthy persons without risk, but in the
unhealthy and the feeble and the decrepit they cannot.
They may be removed as well by caustic as by the knife.
The caustic is as complete in its action, and, with due care
and experience in its use, can be employed just as readily
and quickly as the knife. Have it therefore as a general
rule, for which however I give no more special instances
than these, that where the risk of a cutting operation
would be appreciable, and you can substitute for it the
use of caustic or anything that shall not be cutting, you
should do so.
Another rule : Be quite clear about carrying out
carefully the last stages of all operations. I suspect that
everybody in operating, when he has passed through the
sort of mental tension in which he performs the most
difficult part of what he has to do, when his attention
has been completely occupied in some difficult task to be
achieved, next feels his mind relaxed, his attention less
keen, less ready for exercise than it was before. Be sure
that these are times of danger to your patient. As soon
as the attention ceases to be as keen as possible, you are
in risk of doing some mischief. That strip of plaster
72 THE CALAMITIES OF SURGERY.
that was put round the man's thigh was an instance of
this. I had got through an operation of considerable
difficulty, and the whole trouble seemed to be at an
end : I was less on my guard than I was before ; and I
overlooked that strip of plaster, which, had it come in the
middle of the operation, I should assuredly have at once
seen and corrected.
I have heard of a case in which a sponge was left in
an abdominal cavity after ovariotomy ; and of another in
which a broken- off blade of a pair of bone-forceps Avas
left deep in a wound made for the removal of dead bone ;
but a worse result than in either of these followed an
oversight in a case of my own. A man's nostrils had to
be plugged after an operation for the removal of a fibrous
])olypus from his nose ; an operation of much difficulty,
and much doubt in its course as to what next should be
done. I had completed all that seemed most difficult
and important ; and then came the condition of relaxed,
comparatively inattentive mind ; and one of my colleagues
who assisted me put a plug into the posterior nares.
Tlirough inattention the plug was made without a string
attached to it with which to draw it out ao'ain. I noticed
it directly afterwards, but the thing was done, and it was
said that it was not worth disturbing the patient again to
alter it. But the patient died of that plug, for it could
not be taken out of his nostrils, except by thrusting it from
before; and thrustini]; it in front broufj^ht on another ho3inor-
rhage and that ha3morrhage brought on delirium, and tlie
delirium, exhaustion ; and so through the lack of a piece
of string in the right place the man died. It was omitted
only because at the conclusion of the operation our
THE CALAMITIES OF SURGERY. 73
minds were less intent than at the beginning, less watch-
fnl. All the danger seemed past just when still greater
dano^er was at hand.
One more rule I will give you. Look very carefully
to your apparatus. I have no doubt that you will look
very carefully to the edges of your knives and your saws
and all things that are mighty to handle ; but look to the
plaster, look to the ligatures and the sutures, and all the
things which are commonly called minor. When I have
seen Sir William Fergusson and Mr. Spencer Wells
operate, I have never known which to admire most ; the
complete knowledge of the thing to be done, the skill of
hand, or the exceeding care with which all the apparatus
is adjusted and prepared beforehand. The most perfect
plaster, the most perfect silk, not one trivial thing left
short of the most complete perfection it is capable of. I
have no doubt that the final success of their operations
has been due just as much to these smaller things, as to
those greater things of which they are masters. In
contrast with their work, I have seen operations per-
formed with great skill ; and a piece of bad plaster or
bad silk, or something left at home, has put the patient's
life in danger. Not long ago, I rem'ember, a patient had
secondary haemorrhage after an operation, and the reason
was that the sticking-plaster was bad. One of the things
that was to control the haemorrhage was pressure by
plaster ; the plaster slipped ; and the patient ultimately
died of haemorrhage. Many an operation has been
spoiled by bad silk, or bad needles, or bad something
that was thought too trivial for care. Surgery could
74 THE CALAMITIES OF SURGERY.
supply only too many illustrations of the wise proverb
against those that despise small things.
These are a large number of rules for you to observe ;
and yet there is no one of those which I have laid down
which is not necessary, I will not say for ordinary success
in surgery, but for the avoidance of great calamities.
Xay, there are more rules than these, which you will
soon learn for yourselves : and now, if, after taking all
these cares, you still meet with calamities, you may meet
them with an honest consciousness that you are really
able to say, what people are too ready to say in a mere
useless pretence, that you did your best. One continu-
ally hears it said, ' I did my best ; but these things will
happen ; ' and yet what a man has called ' doing his best '
was not doing so Avell as he had done before, or so
well as he will do next time. Let me urge you against
this. The intense dissatisfaction that follows these failures
makes one very ready to adopt any excuse that can be
given. Men constantly say, ' These things have happened
to better men : they have happened to this or that
person of distinction ; so I need not be surprised at
having them.' There is no more miserable or false plea
than this. Why, if you know that another man has
fallen into a fault, the blame for your falling into the same
ought to be much greater, not less. If any man had run
into a pit unawares, and you, having heard of it, liad
run into the very sam.e pit, it would not exculpate
you to say that a better man than yourself had run into
it ; surely the blame to you would be tlie greater. But
there are some people wlio seem to liave a happy art of
forgetting all their failures, and reineinbering nothing but
THE CALAMITIES OF SURGERY. 75
their successes, and, as I have watched such men in pro-
fessional hfe, years have always made them worse instead
of better surgeons. They seem to have a faculty of
reckoninsf all failures as little and all successes as bi^f ;
they make their brains like sieves, and they run all the
little things through, and retain all the big ones which
they suppose to be their successes ; and a very mis-
chievous heap of rubbish it is that they retain.
There is but one thino^ that T am afraid of in telhng;
you the risks and dangers that I have met with ; and
that is, that you may over-estimate the probabilities of
them, and be afraid of the responsibility which you must
undertake. Well, after all, this incurring of responsibili-
ties is decided rather by temper than by knowledge.
There are some people wlio are ready for anything ; some
that under difficulties shirk all they can. But of this I am
quite sure, and you will see it proved not only in surgery
but in every calling, the men who are most ready to take
responsibilities, and to bear them lightly, are those who
can best estimate beforehand what are the risks and the
difficulties they incur ; the men who, knowing what is
to come, can therefore face it most bravely and with
most success.
Therefore study fairly and fully, beforehand, all the
things that may occur to you, in an operation and after
it : make yourselves, as far as you can, masters of each
case, and generally masters of your whole profession ;
and then you will neither be afraid of your responsibili-
ties nor ashamed of your failures.
76 THE CALAMITIES OF SURGERY.
The risks and calamities of operations have been reduced
even during the few years since the foregoing lectures were
given, but they still are too many and too great, and I venture
to hope that the lectures may help in still further reducing
them.
When I recollect the improvements in surgical practice of
which I have been a witness, none seem to me more gratifying
than those which have not only diminished the mortality after
operations, but have diminished the fever and all the other
troubles apt to follow them. No one, I presume, would venture
to assign to each improvement its share in the diminution.
Mr. Lister's practice and promulgation of his antiseptic treat-
ment ; Mr. De Morgan's use of the chloride of zinc ; sil-
ver-sutures, acupressure, torsion, carbolised catgut-ligatures,
Esmarch's elastic bandage, a steadier belief that the healing of
wounds is a natural process that needs only to be undisturbed ;
these have been the chief means of saving life ; and with them
may be counted the constantly increasing care for healthy
arrangements in hospitals and houses, and for cleanliness and
simplicity. But I suspect that another thing has been more
potent than any one of these, namel}^, the increase of the care
in watching all patients submitted to operations, and in rejecting
the unfit. There has been an admirable rivalry for success ;
treatment after operations has come to be the most interesting
subject of surgical study ; and everyone proposing or adopting
an improvement has watched personally and closely the patients
submitted to its use. The result is, I believe, that the total
mortality and all the illnesses after operations of all kinds are
not more tlum half as great as they were thirty years ago. But
study and care may make them still less, and will certainly do so
if no part of the study be deemed trivial.
n
ON STAMMERING WITH OTHER ORGANS
THAN THOSE OF SPEECH,
The characters of stammering in speech are so well
known, and may be so often studied, that we may take
this form of disease as the type of a class including
similar affections of other organs than those of speech,
and may apply to all the same generic name of ' stam-
mermg.
Stammering, in whatever organs, appears due to a
want of concord between certain muscles that must con-
tract for the expulsion of something, and others that
must at the same time relax to permit the thing to be
expelled. Ordinary stammerers cannot at the same time
regulate the contraction of the muscles of expiration for
the proper expulsion of air, and the relaxation of those
of the glottis, or (in different cases) of the tongue or lips,
for permitting the expulsion of the air while it is being
made vocal and articulate. Numerous as are the varieties
and modes of speech-stammering, this discord of muscles
is in them all. Its dependence on the nervous system
and the mind is in fact plain enough, in theory very
difficult. Perhaps it may help the study of speech-
stammering, if similar disorders be watched in other
parts of the body ; but at present I want only to point
out the facts for their importance in our practice.
78 ON STAMMERING
Stammering urinary organs are not rare ; and tliej
may be known by observing, sometimes in the same
person, the exact parallehsm between the difficulty of
expelhng urine and that of expelhng the air in the ordi-
nary speech-stammering. The patient can often pass his
urine without any trouble, especially at customary times
and places ; and, w^hen he does so, the stream is full and
strong, and he has ' nothing the matter with liim.' But,
at others times, he suffers all the distress that he miojlit
have with a very bad uretliral stricture. ^ He cannot pass
a drop of urine ; or, after a few drops, there comes a
painful check, and the more he strains, the less he passes ;
and then complete retention may ensue, and over-filling
of the bladder. In these characters, the case may closely
resemble one of the ordinary instances of so-called con-
gestive stricture, in which rapid swelling of some part
of the mucous membrane narrows or closes the part of
the canal which is least capable of distension. But the
circumstances in wdiich the difficulty arises are, in the
two cases, very different. The stammering with the
bladder occurs in just the same conditions as the stam-
mering speech. There are few stammerers in speech so
bad but that they can talk or read fluently when they
are alone or with those wdiom they are most familiar
with, or Avhen they are entirely thoughtless as to their
manner of speaking. Their worst times are when with
strangers, or with persons or in places that are associated
in their minds with stammering. It is just so with the
bladder and urethra. One patient told me that, although
lie could usually pass urine well, yet there was one
person with whom nothing could induce him to walk,
WITH THE URINARY ORGANS. 79
because once, when he was with her, he wanted to pass
urine, retired, and failed. His experience of the effects of
association of thoughts made him sure that, if he were
again in the same circumstances, the same distress would
come on him more intensely. Another, a clergyman,
always passed a catheter before going into his pulpit. He
had often had nervous troubles with his bladder ; and once
or more, having felt a horrid need of passing urine while
he was preaching, he found himself, at the end of his
sermon, unable to pass any. He said he felt sure that,
if he were to go into his pulpit without the assurance of
an empty bladder which his catheter (a No. 12, passed
easily) gave him, he should be pressed with the desire
to pass urine, and then should have retention. As a
speech-stammerer might be unable to utter a word, so
would he be unable to pass a drop of urine. Again,
another patient has described himself as driven to all
kinds of devices to bring about the association of ideas
or of actions with which he best succeeds in emptying
his bladder. He must walk up and down his room, and
stand or sit in some customary singular posture, and
then be very careful not to direct his mind either too
much or too little to what he has to do, and then to let
the urine run as inconsiderately as he can.
I might add many more notes of the seeming caprices
of the stammering bladder and urethra ; but it may
suffice to say that nearly all the phenomena of stammer-
ing speech find in them their parallel. In both alike
are observed the strong influence of habit and of associa-
tion of ideas ; the effects of transient changes in the
vigour of the nervous system ; the need of a justly and
8o ON STAMMERING
yet almost unconsciously measured exercise of the will,
that it should be neither more nor less than enough ;
and the influence of distraction of mind. And equally
in both classes of patients may be noticed the coincident
general sensitiveness of the nervous system, and the
family-relationship with persons who suffer various other
forms of nervous disorder.
One or two differences may, however, be noticed
between the urinary and the speaking organs, in their
respective stammerings. The former cause more pain.
The bladder, unable to expel its contents, becomes for
a time the seat of the feelings of distress, tightness and
urgent need of emptying, wliich are felt in more simply
mechanical retention of urine ; and it becomes more
sensitive and more irritable, but probably rather tlirough
the constant and earnest attention of the mind, than
through any change in its own condition. In cases of
long-continued urinary stammering, some of which began
ill very early life, and some of wliicli I have known for
mau}^- years, I have seen no indication of any supervening
organic disease. After years of trouble, nothing appears
wrong but the manner of action of the parts. But though,
so far as I liave yet seen, tlieir stammering does not ])ro-
duce structural disease of tlie urinary organs, yet, in many
instances of their structural diseases, the urinary organs
become very ' nervous ' — that is, very sensitive and dis-
orderly in their nervous systems; and, in this state, they
imitate some of the? fauhs of stammering. Tluis in
stricture, especially from congestion of tlie mucous
membrane of the urctlu'a, patients I'eel tliat a great part
of the (lifficuhy of ])assing urine is due to tlieir inal)ility
WITH THE URINARY ORGANS. 8i
to regulate and harmonise the urinary muscular acts.
As a man said to me, ' If I could stop the straining, I
could do it ; but, as soon as ever I strain, the spasm
comes-on.' By this he meant that he could not duly
moderate the action of the expelling muscles ; and that,
as soon as these began to act too vehemently, those that
close the urethra would act in spite of him. Just so a
stammerer sticks fast in speech ; and the faster, the more
he strains. And, in similar likeness to stammerers, we
may see that most patients with long standing obstruc-
tion from stricture or diseased prostate, or whatsoever
else, resort to habits or postures, or mere tricks, by
which they may gain the advantage of association of
ideas for aiding the successful use of their muscular
power.
The treatment of stammering urinary organs has
difficulties similar and equal to those of treating stammer-
ing speech. The patient must try to educate himself to
a calm control of his muscular power ; and, on any
occasion of failure, must get what help he can from such
mental tricks as I have referred to. He should evade
all risks of difficulty and all the conditions in which he
has suffered his worst failures. He should do anythino-
rather than fail to pass his urine. He should not always
yield to the first impulse to pass it, but should try to
regulate the actions of the bladder to certain fixed hours
of the day. And especially he should learn to use a
catheter, not only that he may thus relieve himself in
case of absolute need, but that he may be free from the
enervating dread of helpless retention. He should keep
his whole economy, and chieily the secretion of urii:e,
G
82 ON STAMMERING
in the healthiest state he can ; for, Hke all other stam-
mering, or in even a greater degree than any other, that
of the urinary organs is influenced by the condition of
the general health.
The characters of stammering with the organs of
deglutition may generally be recognised by their likeness
to those of urinary stammering. They have to be dis-
tinguished not only from the mechanical obstructions of
the upper part of the oesophagus, whether from stricture,
pouch, or other hindrance, but also from the difficulties
of swallowing that depend upon paralysis, whether
hysterical (so called) or senile or from progressive
muscular atrophy. It is not necessary that I should try
to point-out the diagnosis of stammering in deglutition
from each of these diseases. The common ground of
diagnosis from them all is in the predominant influence
of mental association in tlie stammering, and its slight,
if any, influence in any of the other difficulties. Some-
times swallowing is easy and unhindered ; at others very
difficult, especially in company, or when the trouble is
])articularly inconvenient, or the mind too much set on
it. Briefly, nearly all that has been said of stammering
with the urinary muscles might be repeated, mutatis
mutandis^ of that with the muscles of deglutition, and
both may be studied by their likeness to the ordinary
speech-stammering, with which, indeed, they may be
associated in the same person or in the same family. A
man of forty with well-marked stammering in swallow-
ing told me that he had stammered iji sjieech during all
his earlier life, but he now spoke smoothly.
I liavc not seen cases enough to be able to discrimi-
WITH THE (ESOPHAGUS: WITH THE RECTUM. 83
nate between the stammering and the spasmodic stricture
of the oesophagus. I think they are different affections,
but I need more opportunities of studying them. If any
one will investigate them, much help may be gained from
the paper by the late Dr. Brinton in the ' Lancet ' for
January 6, 1866, and from the remarkable case of fatal
spasmodic (or stammering ?) obstruction of the oesophagus
recorded by Mr. Henry Power. -^
I believe that a disorder essentially similar to stam-
mering may be traced among the cases of difficulty of
defsecation not due to organic disease ; but it requires
more study that I have yet been able to devote to it.'^
1 Lancet, 1866, vol. i. p. 252.
^ I have lately seen John J , aged 3|, the child of very nervous and
excitable parents. He has been slow in learning to speak, and now stammers,
sometimes a little, but occasionally very badly. Sometimes he passes large
evacuations without pain or difficulty 5 but often, particularly, his father
told me, when his speech-stammering is troublesome, he spends from half
an hour to an hour in futile attempts at defaecation. On these occasions he
becomes very excited, running about the room, and from one person to
another, apparently in considerable pain, passing his urine at frequent in-
tervals, complaining that he cannot relieve himself, and asking that some
one should rub his stomach. If he is soothed, and humoured he becomes
quiet, and at length his bowels act. Enemata and large doses of purgatives
had failed to remove his trouble, and frequently there is no action for three
or four days. I carefully examined the anus and rectum, and could detect
neither narrowing, valvular obstruction, nor anything else that felt unnatural
in either. — [Ed.]
G 2
84
CASES THAT BONE-SETTERS CURE.
After systematic lectures on the chief injuries of the
bones and joints, it may be useful if I try to enforce by
particular illustrations some of the general principles that
I stated ; and it may secure your attention if I use the
form of speaking of the Cases that Bone-setters Cure.
For few of you are likely to practise without having
a bone-setter for a rival ; and, if he can cure a case
which you have failed to cure, his fortune may be made
and yours marred.
I believe that, in the large majority of cases, bone-
setters treat injuries of joints, of whatever kind, with
wrenching and other movements of them. The proceed-
ing was described to me lately by a gentleman who had
a well marked fracture at the lower end of his radius.
He had been to a distinguished bone-setter, who, with a
glance at the wrist, said : ' You ha' put out your wrist,
that's what you lia' done ; ' then violently stretched and
moved the joint ; then said : ' Now you go and hold that
under my puni]),' and, after the cold douche, took his
fee. The fracture, being none the better for this treat-
ment, was, at a second visit a few days later, again
wrenched, pumped upon, and paid fur. But, this time.
SLIPPED TENDONS. 85
much pain and swelling followed ; and the patient had
the wisdom to call himself a fool, and to go to his usual
medical attendant ; who sent him to me.
Cases of this kind are of frequent occurrence. To the
bone-setter, every injured joint is ' put out ; ' and the
one method of cure is the wrench and the rough move-
ments, by which it is said that the joint is ' put in '
again.
Now, it would be of little use to us to estimate, even
if it were possible, the quantity of mischief done by treat-
ment such as this. It is more important to know and
consider that it sometimes does good ; that, by the practice
of it, bone-setters live and are held in repute ; and that
their repute is, for the most part, founded on their occa-
sionally curing a case which some good surgeon has failed
to cure. For here, as in all similar affairs, one success
brings more renown than a hundred failures or mischiefs
bring disgrace. The patients who are cured never cease
to boast of their wisdom in acting contrary to authorised
advice ; but they who are damaged are ashamed of them-
selves, and hold their tongues.
What, then, are the cases that bone-setters cure with
their practice of wrenchiiig ?
First, of course, they have a certain number of real
fractures and dislocations which they reduce, and of old
ankyloses which they loosen. Of these, I need say no- 2 Z*/*-^
thing ; for I believe there is nothing in their practice in ' /
these cases which is not as well or better done by regular
surgical rules.
Next, there is a rare accident which a wrench may
cure, and which, if you are not on your guard, you may
86 CASES THAT BONE-SETTERS CURE.
fail to make out ; namely, the slipping of a tendon. I
liave known the tendon of a peroneal muscle ^ slip to the
front of the outer malleolus ; and in three instances I
have known the extensor tendon of the middle finger slip
over the heads of the metacarpal bone and first phalanx ;
and here, from our museum, is the long tendon of a biceps ^
sUpped from its groove. Of these accidents, the first two
may be made-out by feeling the displaced tendon and the
oap where it should be ; the third may be at least guessed-
at by the signs which Mr. Soden has pointed out in his
case, related in the Medico- Chiriirgical Imnsactions;^
the slio-ht forward prominence of the head of the humerus,
its drawing up under the acromion, and the pain at the
lower end of the biceps on stretching it. As to this dis-
j)lacement, however, I doubt whether it would be ever so
certainly made-out as to be fairly reduced ;* the others, at
the ankle and the finger, should be remedied by relaxing
the slipped tendon as extremely as possible, and replacing
it with lateral pressure and sudden stretching.
Some other tendons may slip, I beheve, like these ;
tlie tendon of the popliteus appears very likely to do so ;
and I can hardly doubt that a bone-setter has occasionally
done, unwittingly, a lucky trick, when, with wrenchings
and twistings of a joint, he has made some dislodged
tendon shp back to its place.
But there is a set of cases much more common than
tliese, which may be cured with wrenching and rough
movements ; namely, the so-called internal derangements
of joints. The knee-joint '"' is by far the most frequent
' See Note VI. * Ser. v. 0. See Note VII.
» Vol. xxiv. p. 212, et acq. * See Note VIII. ^ gee Note IX.
SLIPPING FIBROUS CARTILAGE, 87
seat of this injury, whatever it is ; but the like occurs in
the lower jaw-joint ; and I have known very similar signs
of injury at the hip and elbow. The most marked sign
is that, while the joint is being moved in some ordinary
action, most often when the foot rests firmly on the
ground, and the thigh is rotated outwards on the leg,
something is felt slipping or suddenly caught between the
bones, and a great pain comes and the joint is locked.
It will move in one direction, not in the opposite one :
just hke a hinge with a stone in it (as a patient described
it to me). The locking of the joint, which is, usually, at
moderate flexion, is soon followed by effusion of fluid into
it, and other signs of more or less acute inflammation of
the synovial membrane ; and, if nothing be done, these
last for some days, or even for some weeks, before, with
subsidence of the inflammation, the joint gradually regains
mobility.
Many of these symptoms are like those due to a loose
piece of cartilage in a joint — a much rarer condition.
But, with loose cartilages, joints are not, I think, often
locked for any length of time ; they are stopped with
extreme pain when the cartilage gets between the bones,
but it soon escapes and they go again. In some of the
cases of what I am calling locked joint, at the knee' or
lower jaw, it is probable that one of the interarticular
cartilages slips and is nipped between the bones. We
have, in the museum, a cast ^ from a knee in which it is
certain that this happened. But in some cases it
seems more likely that a fold of synovial membrane,
or a portion of capsule, or of synovial fringe, is
^ See Note X.
(
88 CASES THAT BONE-SETTERS CURE.
caught and nipped. However we may explain tlie
accident, it is one of those that may be cined by the
bone-setters. Such movements as theirs are not always
necessary ; and none should be practised recklessly or
without plan ; but force may be requisite, and, if used
knowingly, will certainly set a locked joint right again.
Sometimes a patient learns for himself how to unlock
his joint, and can do it gently, first, in the case of the
knee, bending and then with slight rotation slowly
stretching it. But he may need more force than he can
use for himself; and you may apply it better than a
bone-setter can.
In the case of the knee, the ' lock ' usually takes
place with the joint moderately bent and the leg rotated
outwards. You must unlock it by extremely bending
the joint, then rotating the leg inwards, and then suddenly
and forcibly extending it. In the same manner, for any
other joint that appears to slip and lock, you must
observe the direction in which the patient can easily
move it, and the direction in which movement is im-
possible or very painful ; then you must move it, first,
extremely in the former direction, and, secondly, forcibly
in the latter. The manoeuvre is sometimes very painful ;
and the force required for success may be greatly
augmented by muscular resistance. In either case, the
use of ether or chloroform may ease both the patient
and yourself.
A fourth set of cases that may be cured with wrench-
ing, or other forcible movements, includes those in which
injured joints are held stiff, or nearly stiff, by involuntary
muscular action. You may meet with such cases in
MUSCULAR STIFFNESS OF JOINTS. 89
patients of any age ; but they are most frequent among
the young. Somethnes after well treated fracture near
a joint ; sometimes after a sprain ; sometimes when a
joint has been hit hard — stiffness remains, which is due
solely to muscular action ; and this stiffness in some cases
is constant, and in others ensues on slight attempts at
motion.
Any joint, I believe, may be in this condition at any
time after an injury. I have seen it at the elbow,
shoulder, cervical spine, hip, knee, and ankle ; in some
instances a few hours after the injury, in some, several
weeks. You may know this muscular kind of stiff joint
by this, among other signs : that the stiffness is not a
dead block, as if by meeting of displaced bones, nor has
rigid resistance, but yields a little, as if with the ' giving '
of a firm elastic substance which instantly recoils.
Besides, you may generally feel the muscles in action ;
not hard and vibrating as if with all their force, but firm,
steady, and resisting. If, however, you have any doubt
about the diagnosis, chloroform will settle it. As soon
as the patient becomes quite insensible, the muscles relax,
and the previously stiff joint becomes freely moveable.
Herein appears the best mode of cure. When the
patient is under chloroform, move the joint quietly, and
then confine it with splints in a posture opposed to that
in which it was stiff. After a day or two, it may be
moderately exercised, douched, and shampooed ; but in
the intervals of this treatment the joint should be con-
fined with the splints, if it should appear to be becoming
stiff again.
You may sometimes see another condition, very like
90 CASES THAT BONE-SETTERS CURE.
this involuntary muscular rigidity of joints, in young
children. If one of its limbs be hurt, a young child will
sometimes hold the limb steadily in one position, and
complain if it be moved. Thus, a child, whose thigh has
been strained, will stand on the other leg and keep the
hurt thigh lifted up, as if for extreme disease of the hip-
joint ; or, for similar hurts, will, for even many days,
keep its arm close to its side, or its elbow-joint steadily
bent.
Perhaps, some of these cases are the same as those I
last spoke of ; but in many of them the muscular fixing
of the part has seemed to me not involuntary. It is more
like a trick, or an instinct of fright lest the part should
be hurt again. Certainly, the muscles relax instantly in
sleep, and not unfrequently when the attention is dis-
tracted from them.
I suppose that bone-setters would cure this state with
tlieir panaceal pulling ; but, happily, they are allowed
to have but little practice among children. Happily, I
say, for children's joints are much more imperilled by
violence than are those of older patients ; and you cannot
be too cautious in concluding, when a child holds a joint
fixed, that there is really no disease or serious injury.
All the evidence must be negative ; and an oversight
may be disastrous.
However, you need not use any kind of force in this
kind of contraction in a child. If the part be only
allowed a few days' rest, it will get well ; unless, indeed,
it be seriously damaged — in which case, you will have
done well by avoiding all violence.
In another set of cases, there is no doubt of the
SPRAINS. 91
voluntary character of the muscular rigidity of a joint.
You saw lately a girl in Lawrence Ward who wilfully
resisted all movements of a hip that had been only
shghtly hurt. If a bone-setter had wrenched her joint,
it might have served her right, and the pain might have
cured her temper. But she recovered just as well when
she saw that she did not deceive us and was not pitied.
You may expect to find cases of joints wilfully held stiff
among the worser sort of school-boys, and they sham
pain as well as stiffness. It is lucky for them when they
can escape punishment or disgrace by lying and letting
the bone-setter be believed, when he professes that he
has ' put-in ' their dislocations.
Now, among all these cases of muscular difficulty,
there is a good harvest for bone-setters ; and, without
doubt, their remedy, rough as it is, is often real. Yours
may be as real, with much less violence ; and, with better
diagnosis than they can ever make, you may do none of
the harm that they often do.
But there is a yet larger class of cases which bone-
setters sometimes succeed in curing very quickly ; namely,
ordinary sprains.
I cannot doubt that some recently sprained joints
may be quickly cured, freed from pain, and restored to
useful power, by gradually increased violence of rubbing
and moving. This method of treatment has many times
been introduced into regular surgery ; but it has never
been generally adopted, or, I think, long practised by
any one. I suspect that it sometimes does no good, and
sometimes does harm enough to disgust a prudent surgeon.
I believe that the best mode of applying this plan of
92 CASES THAT BONE-SETTERS CURE.
treatment is, to begin by handling, rubbing, and pressing
the sprained part and its neighbouring structures very
gently. After doing this for fifteen or twenty minutes,
the rubbing and pressing may be increased in hardness,
and the joint may be more freely moved, especially in the
direction opposite to that in which it was forced by the
accident. Another quarter of an hour or more thus
spent, is to be followed by rougher proceedings of the
same kind, till even severe pressure and wide and violent
movements can be borne without pain ; and then, in an
hour or so, the cure is deemed complete, or so nearly
complete as to require only a slighter treatment of the
same kind on the next day.
I cannot tell you in what kind or proportion of recent
sprains you may employ this treatment ; indeed, I cannot
advise you to use it at all, unless by way of trial in very
healthy men. For I do not doubt that it will sometimes
do harm ; and the greater quickness of cure which it may
achieve is not worth a risk, while we can always employ
such safe, and not slow, means as the combined rest and
support of the sprained parts wliich are given by strapping
or tlie starched or plaster-of-Paris bandage. In short,
this rough-rubbing and hard-pulling treatment of recent
sprains seems to me one of those dangerous remedies
wliich, though I believe in their occasional utility, I
would rathur not cni])loy till I can discriminate the cases
in which they will do good from those in which they will
do harm.
Such discrimination, difficult as it may be among
recent sprains, is not very difficult among old ones; that
is, among cases in which the ill effects of sprains remain
OLD SPRAINS. 93
long unciired. It is among these cases that bone-setters,
and especially those who combine rubbing and shampooing
with their ' setting,' gain their chief repute, and not with-
out some right.
Among ' old sprains,' you will find a strange variety
of cases — chronically inflamed joints, each probably bear-
ing the marks of the constitutional disease or unsoundness
of its possessor, and loose joints, and slipping, and creak-
ing, and weak, and irritable joints, and many more. To
all these, mere bone-setting does harm, or no good ; and
rubbing and shampooing are of little, if any, use ; indeed,
to a really inflamed joint they would generally be mis-
chievous. But among ' old sprains ' are not a few cases
in which a joint, after long treatment, remains or becomes
habitually cold. It is generally stiflish and weak, sensitive,
aching after movement, or in the evening or at night,
sometimes swollen, puffy or oedematous, but not with an
' oedema calidum.' Whatever else it is, it is cold, or, at
the most, not warmer than the healthy fellow-joint.
Among these cold joints, bone-setters and rubbers gain, as
I said, great repute ; and all the more because they often
get the cases after the patients have become tired and dis-
contented with a rather over-careful surgery. Admirable \
as is the rule of treating injured joints with rest, such i
rest may be too long continued ; and in every case in v
which it has done full good, it must, in due time, be left
off. With rest too long maintained, a joint becomes or
remains stiff and weak and over-sensitive, even though
there be no morbid process in it ; and this mischief is
increased if the joint have been too long bandaged, and
still more if it have been treated with the cold douche.
/
94 CASES THAT BONE-SETTERS CURE.
I need hardly say that it may be sometimes difficult
to decide the time at which rest, after having been highly
beneficial, may become injurious ; or that the decision is
always a matter of grave importance. On the one hand,
you and the patient may be losing time through over-
caution ; on the other, the risk may be incurred, through
rashness, of renewing inflammation in a damaged joint.
I believe you will be safe, if 3'ou will take the temperature
of the part for your guidance. If the part be always
overwarm, keep it quiet ; if it be generally cold, or cool,
it needs and will bear exercise and freedom from restraint
of bandages, with friction and passive movements, and
other similar treatment of the reviving kind. And of
this you may be the more sure when the cold integuments
over the joint are dusky-pink or purplish, or become so
when the limb hangs down, and when there is little
swelling, and when pain is Qiuch greater than is accounted
for by any appearance of disease.
I do not know whether bone-setters make any discri-
mination among these cases ; and I do not advise you to
adopt their rough method in all or in most cases, for
though they may, when successful, prove emphatically the
utility of movements for old sprains, yet the same good
may be more safely done with gentler means of the same
kind. Exercise of the hurt part should be gradually
increased, and always followed by long repose ; and the
frictions and shampooings should be gradually made
harder and more rough, and the passive movements
gradually extended. Always, the part, if itself cold,
should be. by any means cxccj)! bandages, kept warm ;
and always the patient's constitutional defects should be
HYSTERICAL JOINTS. 95
watched, and, if possible, amended ; for very commonly
the chief hindrance to the recovery of a sprain is not local,
but some general wrong — gout, chronic rheumatism, or
struma, or hysteria, as it is called.
An ' hysterical joint ' is, indeed, sometimes a rare
opportunity for a victory for a bone-setter. Cold, weak,
useless for want of power of will, intensely sensitive,
subject to all the seeming caprices of a disorderly spinal
cord and too vivid brain, — such a joint as this may be
cured by the sheer audacity with which it is puUed-about.
If nothing in it but its portion of the nervous system is in
fault, this may be sometimes cured through influence on
the mind. And so not only bone-setters, but the workers
with Mesmerism, and tractors, and oils, and distant or
superficial electricity, can sometimes cure hysterical joints:
for the patients love to be cured with a wonder ; and the
audacious confidence of all these conjurors is truly
wonderful.
From all this, you may see that the cases that bone-
setters may cure are not few. I think it very probable
that those in which they do harm are numerous ; but the
lessons which you may learn from their practice are plain
and useful.
Many more cases of injured joints than are commonly
supposed to be thus curable, may be successfully treated
with rough movements — wrenching, pulling, and twisting.
The cases that are thus curable I have endeavoured to
point out to you. Be on the watch for them. But
remember always that what may be treated violently
may be treated more safely and as successfully with com-
parative gentleness ; and that, in some cases, you may
96 CASES THAT BONE-SETTERS CURE.
very advantageously use chloroform or ether. And
remember, also, that no degree of violence, not even
such movements or exercises as I have advised, can be
generally safe in the treatment of injured joints, unless
when directed with a skilful discernment of the appro-
priate cases.
Learn then to imitate what is good and avoid what
is bad in the practice of bone-setters ; and, if you would
vStill farther observe the rule. Fas est ah hoste doceri,
which is in no calling wiser than in ours, learn next what
you can from the practice of rubbers and plasterers :
for these also know many clever tricks ; and, if they had
but educated brains to guide their strong and pliant
hands, they might be most skilful curers of bad joints
and of many other hindrances of locomotion.
Since the publication of this lecture, a valuable essay
on bone-setting has been published by Dr. Wharton
Hood,^ Avho has thoroughly learned the art, and practises
it skilfully. He fully describes the several methods of
manipulation, and no one can doubt their value when
used prudently.
My later experience, as well as Dr. Hood's essay,
makes me believe that my account of the 'cases that
bone-setters cure ' is not very faulty. I have made some
corrections in it, and have some things to add.
Chiefly, I would add emphasis to what I have said
of the mischief of keeping injured joints too long at rest,
or too cold. Too long rest is, I believe, by far the most
' M)n Bone-Setting-,' 1871.
DR. HOOUS ESSAY. 97
frequent cause of delayed recovery after injuries of
joints in nearly all persons who are not of scrofulous
constitution. In tlie healthy, the chronic-rheumatic, and
the gouty, it is alike mischievous ; and not only to
injured joints, but to those that are kept at rest because
parts near them have been injured. Mere long rest
stiffens them, and makes them over-sensitive ; cold
douches and elastic restraints and pressures make them
worse, and nothing remedies them but movements,
whether forced or voluntary.
I have seen a case, in which, after amputation of a
finger and sound healing, the hand, having been kept
long at rest, became so sensitive that the slis^htest touch
was intolerable, and even the vibration of a church-
organ, while the patient was standing near, was painful.
The hand w^as extremely wasted, but there was no ap-
pearance of disease in it.
Dr. Hood's essay should be read on all these cases,
not only for the manual treatment which he teaches, but
for the signs which he indicates as decisive in the choice
of cases. He believes that the success of ' bone-setting '
in them is due to the rupture of adhesions ; and this may
well be. I have seen such adhesions in the ankle-joints
of legs amputated after being long at rest, though the
joints had not been evidently inflamed; and Mr. Butlin^
has related a case of ankylosis of a knee-joint in a limb
which was long kept straight for the treatment of a
fractured femur. But even without adhesions a joint
long at rest may become restrained in certain movements
by the gradual shortening of all those parts of its liga-
1 < Trans. Pathol. Soc.,'v ol. xxv. p. 212.
H
7
■ff
98 CASES THAT BONE-SETTERS CURE.
mentous structiiies which have been constantly relaxed,
and it is hkely to be very painful when a strain is put
upon these shortened stnu^tures to restore them to their
natural length.
Among the most frequent instances of painful stiff-
nesses induced by long rest of unhurt joints, are those of
the fingers after fractures of the fore-arm, and especially
after fractures of the lower end of the radius. And this
gives me occasion to say that, of the many inventions for
treating this fracture, all are bad which hinder the easy
movement of the phalanges of the thumb and fingers.
Another set of instances are those of the tarsus, which,
though itself unhurt, may remain stiff and painful after
diseases and injuries for which the leg has been long
kept at rest. These are not met with, I believe, when
the foot has been kept at a right angle with the leg, as
in every such injury it should be. In this posture it will
bear, without strain or pain, the weight of the body when
walking is resumed.
Other similar groups of cases might be cited ; but
they would all come under the general descriptions of
joints becoming stiff and painful, or unable to bear the
strain of ordinary movements, through being kept too
long at rest. And if I should be asked how soon an
injured joint may be safely moved or allowed to bear
weight, I should say, generally, as soon as it is cool
during any considerable part of the day, and not at every
part tender on pressure, and not painful when its articular
surfaces are pressed together. But, particular judgments
may have to be formed in the cases of the vscrofulous,
the ' hysterical,' and tlie gouty ; in the first, rest is seldom
STRAINED SPINE. 99
too long ; ill the second, seldom too short ; in the third,
the general health must be considered.
As to the methods of moving the joints thus stiffened
and painful, it is sufficient, in a very large proportion of
cases, if the patient will resolutely use them ; bearing
some pain and not fearing it as if it were a sign of disease
either present or impending. In the worse cases, violent
movements must be used ; and I believe the best will be
such as Dr. Hood describes. Ether or chloroform may
be used, and w^ill sometimes save violence- by finding that
much of the rigidity is only muscular. But I must add
that in all but the shghtest cases, or the '^only nervous,'
the forced movements are only the beginnings of cures.
The popular belief, that the cure by bone-setting is com-
plete at once, is erroneous ; a good start is obtained with
great eclat ; but voluntary resolute exercises, or repeated
forced movements, are necessary to maintain or increase
the advantage first gained.
I have not mentioned in the lecture, a set of cases
which are said to be sometimes cured by bone-setters,
and in which, after strains or other injuries of the spine,
stiffness and aching long remain, and especially pain or
tenderness over one spot at which, the patients sometimes
tell, a crack or a slip was felt at the time of injury. I
have seen several of these cases, chiefly in nervous and
over-sensitive women and girls : bone-setting, I have
heard, has cured some ; in more, I know that it has failed ;
and these have slowly recovered without any evident in-
fluence of treatment.
H 2
ICO CASES THAT BONE-SETTERS CURE.
On these and, indeed, on all the cases of which I have
been speaking, I recommend the study of Dr. Hood's
essay. It may enable any surgeon to do what I advised ;
' to imitate what is good, and avoid what is bad in the
practice of bone-setters.'
lOI
ON STRANGULATED HERNIA.
LECTURE I.
•
I PROPOSE to give you some lectures on Strangulated
Hernia, a subject of great interest in practice, and one
which you should do your best to learn while here ; for
it is only in a large hospital that you can see many cases
of hernia, and only by the study of many cases that you
can prepare yourselves for the great variety with which
you may have to deal.
While I was on active duty at the hospital, I operated
(in the hospital and in private practice together) on about
a hundred cases of strangulated hernia, and I kept full
notes of nearly all these as well as of some in which my
colleagues operated. It is from these notes, and from the
memoranda of several clinical lectures, that I shall draw
materials for my present scheme.
It may seem to you that a hundred cases of strangu-
lated hernia should be sufficient for some statistical
deductions ; but they are not nearly enough. The
varieties of hernia, their complications, and the didbrent
conditions of people in whom they occur, make so great
a variety of cases, that it would need a tabulation of at
least a thousand cases to obtain conclusions of real value.
I02 ON STRANGULATED HERNIA,
I shall, therefore, use my notes and recollections only to
enable me to tell you what appear to be truths on some
of the most huportant practical parts of the subject.
Our first subject may be the grounds for determining
whether a strangulated hernia, or one supposed to be so,
is to be submitted to operation. Speaking generally, one
may say that when in a case of hernia signs of strangula-
tion are present, and reduction by the ordinary means
cannot be accomplished, the operation for reduction
should be at once performed. But then, what are the
sufficient signs of strangulation? and what are the ordinary
or, better, the reasonable means for reduction without
operation ?
In all well marked average cases, that is, in such as
are neither slight nor very severe, neither (as some divide
them) acute nor chronic, these following may be regarded
as the signs of strangulation justifying operation. The
hernia, usually reducible, or now first formed, cannot be
reduced by reasonable means. If not recently formed, it
is larger tlian usual, tense, firm, or even hard ; without
impulse, without resonance ; painful, and tender on pres-
sure, especially at its moutli and neck. The bowels do
not act, though they may often be felt contracting, and
may cause nmch colic and spasmodic pain, especially
at the navel and the pit of the stomach. With this pain
tliere is commonly some tenderness, with a feeling of
tightness, in the abdomen, especially about tlie navel and
between it and the seat of the hernia. The patient is
often sick, vomiting nearly all the food and drink that he
swallows and, besides, a quantity of gastric and bihary
secretion, or of the contents of the small intestines more
S/GNS OF STRANGULATION. 103
or less diluted. The pulse and respiration are usually
quickened and rather feeble ; the patient feels and looks
restless, low, and miserable — or, as it called, 'anxious.'
He cannot sleep or eat ; and the hands and feet are apt
to become cold shrunken and dusky.
Whenever all these things are observed, and when
they remain after such reasonable attempts at reduction
without operation as I will presently speak of, you may
hold that the operation should be done without delay.
Much more, if possible, should it be done if these things
be all worse than I have described. When the integu-
ments over the hernia are iniiamed, thick, sodden, and
ruddy, or emphysematous ; when the whole abdomen is
swollen, tense, and tender; when the vomit is just like
the liquid fasces of the ileum ; the pulse very rapid, feeble,
and small ; the skin cold and dusky and clammy ; when
the patient is dim in sense and mind, or in an anguish of
misery with retching and hiccough ; when all or the
greater part of these elements of what the old writers
called a miserere are combined ; then, without trying any
other method of reduction, you must instantly operate,
though you may have only the slenderest hope of doing
good, and a serious fear of seeming to do harm.
Thus far, one may speak very positively. In the cases
which I have skeU^Jied, these are the sufficient signs of
strangulation ; and if the hernia cannot be safely reduced
without operation, the operation must be done. But you
will not see many cases without seeing some in which,
although the hernia may be irreducible, yet the signs of
strangulation are very slight, obscure, incomplete, or in
some other way not sufficient to make it nearly certain
104 ON STRANGULATED HERNIA.
that the operation is necessary. It is an easy rule for all
these cases that, whenever yon suspect that a hernia is
strangulated, you should operate. If you will follow this
easy rule, you will do some very bad surgery ; you will
kill a few patients whose lives you ought to save ; and
you Avill make many ill for two or more weeks who might
be well in as many days or hours. You must avoid the
easy rule, and learn the hard one of discriminating the
cases that require operation. You must learn to dis-
criminate those in which the operation must be done at
once, without any previous attempts at reduction, and
those in which before operation one or more attempts at
reduction should be made with ether, chloroform or
other helps. For the purpose of discrimination, let it be
your design, in each case of strangulated hernia, not to
choose any measure for its reduction till you have fairly
weighed the signs of strangulation of which I have
spoken. For convenience of thinking, you may divide
them into local symptoms, including all the characters
of the hernia itself, and the remote or general symptoms,
especially the inactive bowels, tlie state of the abdomen,
the vomiting, the pulse and respiration, and the general
condition. I will try to tell liow each of these, in its
several degrees, may be estimated.
1. First, of the local symptoms, the irreducibility of
the hernia, its unusual size, its tension or hardness, and
the otliers which I enumerated, a few rules may include
all that I can tell. It will be convenient to speak of
irreducibility last ; for, though it may seem as if it should
be the condition decisive for operation, it is really a
fallacious si^ni of strangulation ; and, in some instances,
LOCAL SIGNS OF STRANGULATION. 105
no trial should be made to test its existence. As for the
other local symptoms, their presence, in even a marked
degree, is not decisive of strangulation, and is not suffi-
cient to prove the need of operating when the remoter
signs are not present. For the local symptoms may be
found when a hernia or its sac is acutely inflamed,
though not strangulated. In this state, which may follow
injury, or even arise spontaneously, a hernia may become
quickly larger than ever, firm and very tense, without
impulse, very painful and tender, hot and red, and not at
once reducible by any fair means. The sac may suppurate,
the integument may slough ; and yet there may be no
strangulation and no need of an operation. I have,
indeed, onlv once seen this slouo^hinor of the intei^uments
over a hernia ; but the case is not likely to be without
parallel, and was a glaring instance of the fallacy of the
local signs of strangulation.
A very stout elderly lady had a large umbilical hernia,
which became painful, tender, and irreducible ; her bowels
did not act, and she felt sick, but did not vomit. There
appeared no urgent need for operation, and she was one
in whom an operation was not to be undertaken lightly.
But, after three days' watching, during which the local,
but not the remoter, signs had somewhat increased in
severity, I found that a large portion of the thin integu-
ments covering the hernia had rapidly sloughed. I
operated at once, though with little hope of doing good ;
for I supposed that the contents of the sac must also have
at least partially perished. But they Avere not even
severely strangulated ; the month of the sac was too small
for their return, but they were not tightly girt, and the
.^iT
io6 ON STRANGULATED HERNIA.
intestine was only moderately congested. The sloughing
of the integuments seemed due to inflammation in a very
feeble person and an ill-nourished part ; and with the
same feebleness the patient died on the day after the
operation.
You may find then, and not I'arely, that the local
characters usually present in a strangulated hernia may
l)e imitated in an inflamed hernia which is not strangu-
lated. And, though very rarely, many of the remoter
signs — the constipation and the vomiting, the quickened
pulse and breathing, and the rest — may exist when a
hernia is inflamed but not strangulated. How, then,
can you discriminate ? Generally thus : in the inflamed
hernia, without strangulation, the local signs precede, and
greatly predominate over, the remoter and general signs ;
while, in a hernia which is inflamed after becomine:
strangulated, the remoter and general signs will still pre-
dominate over the local, and the history will tell that
they preceded.
These means of discrimination, however, will not
always suffice. You will meet with cases in which you
will be uncertain whetlier the hernia be only inflamed
and irreducible, or strangulated and inflamed ; but in
these cases you must not be uncertain of your practice.
If you cannot very easily reduce the liernia, you must
operate. The risk of operating on a hernia which is
inflamed and not easily i-educible is very small, in com-
parison with the risk of leaving one which is inflamed
and strangulated ; and even if you can find reasons for
waiting, it must be with the most constant oversight, for
an inlhimed and irreducible hernia may at any time
LOCAL SIGNS OF STRANGULATION. 107
become strangulated, and will certanily do so if not re-
lieved by rest and other appropriate treatment.
For a second rule : if the remoter signs of strangula-
tion be present, the local signs are urgent for speedy
operation in the same degree in which they are marked,
or in even a greater degree ; for severe strangulation is
often associated with slight local symptoms.
But, to judge rightly from the local symptoms, each
may need to be carefully weighed as evidence for the
necessity of operating, or of adopting other methods of
reduction.
In reference, then, to the chances of reducing a hernia
without operation, it is a bad omen when one has quickly
come down much larger than ever before. A great
majority of patients give this as the beginning of their
troubles. Sometimes they tell that, while making a great
effort, they felt the descent come larger than ever ; that
they felt some pain or more than usual increase in the
hernia, and could not reduce it in the customary way.
More often the larger descent has happened without
apparent cause. While the patient was sitting, or in bed,
or quietly walking, the descent has occurred ; but,
perhaps, most frequently it has seemed connected with
some diarrhoea, or colic, or spasmodic pain, or with some
kind of turbulent movement of the intestines, for some
hours, or a day or two, before the descent. In some
cases, moreover, the unusual size of the hernia is attained
at once ; in others by gradual increase. In some it very
quickly becomes painful ; and these are rather less likely
to be reduced than those in which pain follows more
slowly.
io8 ON STRANGULATED HERNIA.
I cannot give you any satisfactory explanation of
these unusual descents of hernige or of their becoming
strangulated ; but let them teach you not to be deceived
by any notion, that some unusual or startling event is
necessary as a cause for the strangulation of an old hernia.
I believe it may be held as a safe rule in practice, that
the more a recently descended hernia exceeds its usual
size, the less is the probability of its being reduced with-
out operation ; and I think that the probability becomes
the less, the more the size of the hernia continues slowly
to increase ; for not a few of tliose that have suddenly
become very large, and then have not increased, may be
reduced without operation, if the patient be put under
ether or chloroform soon after the descent.
Similarly, when general signs of strangulation exist,
the harder and more tense a hernia is, the less is the
chance of reduction without operation. The hardness
may be due to any one of several conditions ; but, to
whatever it may be due, it is an untoward sign. It is
especially so if the hernia be a small one. In large
hernias, the hardness may chiefly be felt at and near the
neck and mouth of the sac, especially in inguinal hernias ;
and you must take care not to be deceived by a sac whicli
is soft and flaccid everywhere except at its mouth ; for
there may be strangulated intestine in the moutli of the
sac, though tlie rest contain only soft omentum or fluid
not sufficient to distend it. Nay, you must not let even
a wholly soft condition of the hernia, or an open external
ring, weigh-down against the well-marked general signs
of strangulation ; for the piece of intestine at the moutli
LOCAL SLGNS OF STRANGULATION. 109
of the sac may be too small to give a sensation of hard-
ness, or the whole hernia may be omental.
Again, if the general signs of strangulation exist, the
more painful and tender a hernia is, the less, speaking
generally, is the chance of reduction without operation.
But here it is to be observed, ti\at this rule holds less for
recent than for old lierniaB. A recent hernia may be
horribly painful, apparently because of the tension of the
stretched fibrous tissues about the sac's mouth. Yet such
an one may commonly be reduced with the help of chloro-
form ; but an equally painful old hernia, or one that has
slowly become thus painful, may require speedy operation.
And the operation must be all the more certainly done
when, together with any of the remoter signs, there are
other local signs, such as inflammation of the coverings
of the sac, suppuration, emphysema, or the like. These
are imperative for operation, without any previous attempt
at reduction.
And for another rule : if the remote signs of strangu-
lation be well marked, and the hernia cannot be other-
wise reduced, you must operate, though there may be no
marked local sign at all. Or, even beyond this, if the
general signs of a strangulated hernia be present — the
constipation, vomiting, and others — and there be any-
where a swelling which may be a hernia, though it seem
not likely to be a strangulated hernia, the operation must
be performed at the seat of that swelling.
Eeasons enough for this rule may be found in the
many cases in which the local signs of a strangulated
hernia are so little marked that the patient, having his
attention spent on the misery of his vomiting and epigastric
no ON STRANGULATED HERNIA.
pain, and other symptoms remote from the hernia, says
nothing of the hernia itself. In not a few of my recorded
cases, the hernia had been overlooked for a day or more ;
and the patient had been treated for spasms, colic,
dyspepsia, or some other imitated disease, while the
hernia was obscurely becoming hopelessly strangulated.
This last rule, of operating though there be no local
signs of strangulation, may lead you into trouble ; into
the trouble and discredit of performing an useless opera-
tion, and seeming to do much more harm than good.
But this you must face ; it is just in instances such as
this that surgery must incur the risk of seeming to do
harm rather than miss the opportunity of doing good.
I have operated thus uselessly in three cases. One was
an irreducible umbilical hernia, in which there was no
strangulation, but vomiting and other signs of strangula-
tion, caused by (I believe) gall-stones. Another was a
simple femoral hernia, with an internal strangulation of
a piece of intestine far away from it. The third was an
inguinal hernia with tlie same complication. All the
])aticnts died, and my operations seemed worse than use-
less failures. But you must face this risk of seeming
wrong.
You may have to go furtlier than in these cases ; and
if, for instance, a patient liave two liernias that are irre-
ducible, and signs of strangulation, and you cannot tell
which is strangulated, you must operate on both. I saw
Mr. Stanley do this ; and no one could blame him,
though, when death followed, it was found due to an
internal strangulation distinct from both the hcrniic.
These are the chief rules, so far as I have been able
INACTION OF BOWELS. in
to learn, according to which you may use the local
symptoms of a supposed strangulated hernia as a part of
the evidence for determining for or against an operation
for reduction. And to these it may be briefly added
that the local symptoms are generally less severe in the
old than in the young ; in old hernise than in new ; in
omental hernise than in intestinal.
Let me now go on to speak of the guidance to be
derived from the remoter symptoms ; and, first, from the
inaction of the bowels. This inaction, or rather this
hindrance of expulsion, is a nearly constant sign in
strangulated hernia, but occurs in so many other cases
that its sole presence is of little weight among motives
for operating. Its absence is, rather, that which needs
study.
One or more actions of the bowels, after other signs
of strangulation have set-in, are of no weight at all
against the propriety of operating. They commonly
occur, because usually after strangulation the part of the
bowel below the constricted part empties itself. These
actions of the bowels are not to be counted on either
side of the question about reducibility or operation ; and
even a regular and frequent action is not an absolute
prohibition, for the strangulation may involve only
omentum, or only a part of the circumference of a
portion of intestine. In these conditions, faeces may pass
along the canal and be discharged.
I had to see a lady for what was considered an
abscess in her groin. The swelling was just over the
femoral ring, and contained fluid and air. I punctured
it, and let out pus and air and liquid fasces, and presently
112 ON STRANGULATED HERNIA
I found a piece of hernial sac slougbed-off and lying in
the abscess. Tliis and the history of the case proved
that the hernia had, about a week previously, descended
when the patient felt a sudden pain while driving. The
hernia was so small that it was overlooked; its pain and
the griping which it caused were thought due to colic,
and were so treated. The bowels acted sufficiently, and
gradually the little hernial sac and its enclosed piece of
the intestinal wall died and sloughed-off. Then came
the signs of abscess over the femoral ring, and its outlet ;
and this was followed by complete healing and many
years of health.
However, such cases as this are very rare ; and you
may hold by the general rule, that you should not operate
when the bowels act frequently or regularly, unless all
the other signs of strangulation, both local and remote,
be well marked.
The state of the abdomen is as little or less decisive
in cases in which you may be in doubt. Of course, if it
be sensitive and tender on pressure, either everywhere
or in parts near the hernia, still more if it be distended
and the muscles hard, this is an addition to the reasons
for operating, and, I may add, to the reasons for fearing
that you may be too late. It is more to be remembered
that, when the abdomen is not tense or tender, when it
may even feel nearly natural, yet you must operate if
other signs of strangulation be present, and the hernia
cannot be put back. For tlie changes of tlie abdomen
are not common near the beginning of stranguUition, and
to wait for tlicm would often be to wait too long.
ir I were asked which of tlie signs of strangulation I
VOMITING. 113
would most rely on as commanding the operation, I
should certainly say the vomiting. Time after time, when
the other signs were feebly, if at all, marked, the vomiting
has been a sufficient guide to a timely operation. Many
times, when all else was so quiet that it seemed rash to
operate, the vomiting proved that it would have been
much more rash to wait ; and not one instance can I find
in my notes in which neglect of the import of vomiting
was not proved to be unwise. You had better hold the
rule complete, that, when a patient has a hernia, recently
become irreducible, and, with this, vomiting which cannot
be clearly assigned to something independent of the
hernia, you should operate. I am obliged to say recently
become irreducible, because a patient with an old irre-
ducible hernia may vomit, as any one else may, without
any reason for suspecting strangulation ; though in even
these old cases you must be very watchful lest the vomit-
ing be an early sign of strangulation. But the rule is
safe that recent irreducibility and vomiting are enough
to justify the operation, even though there be no other
signs of strangulation present. Much more must the
operation be deemed necessary when with these the
other signs of strangulation, in even slight degrees,
coincide.
And in thus judging of the vomiting, do not be too
scrupulous as to its manner or its products. There are
indeed some notable modes of vomiting when intestine
is strangulated. The patient vomits all he drinks, and
that soon after taking it ; and besides, he vomits fluids of
his own secreting ; and this vomiting is commonly (at
least in the later stages), with guslies of large quantities
I
114 ON STRANGULATED HERNIA.
of fluid, without mucli retching or violence, as if the
stoKiach slowly became full of its own secretions and of
those of the upper part of the intestine, and then, without
any preceding nausea, suddenly emptied itself.
When you see these kinds of vomiting with a hernia
lately become irreducible, or even with any swelling that
,may be a hernia, you may be sure that you must operate.
But do not wait for any supposed characteristic mode of
vomiting ; do not be misguided by the absence of some
peculiar fluid ; nay, do not be misguided by the absence
of all vomiting ; for I have known it absent in the case
of a very large hernia, w^hich was certainly strangulated,
and on which I operated successfully. And do not be
misguided by an apparent diminution in the severity or
in the frequency of vomiting, or by the vomiting having
begun as soon as the hernia descended ; for this it often
does. Any kind of vomiting, if it be repeated, is enough
to justify operation in a hernia recently become irre-
ducible. Let me tell an illustrative case, which taught
me the more because it occurred in one whose life was
of great value. He was elderly and weakly, but laborious
in literature. For three days after the descent of a hernia,
wliich could not be reduced as it usually had been, tliere
was not a single sign of strangulation, except this irre-
ducibility, constipation, and occasional vomiting. He
had no pain in or near tlie liernia ; no feehng or aspect
of illness ; no hardness or tension of the sac ; and the
vomiting was only occasional, and there were often many
hours of interval. But, after the three days, abdominal
ptiin suddenly set in, with coldness and fiintness and
wretchedness. With in two hours I operated ; but \\, was
GENERAL SYMPTOMS. 115
too late ; peritonitis had already begun, and the operation
was useless or worse than useless. He died in twenty
hours.
Cases like this are frequent. All seems pretty well ;
and then comes an inrush of indomitable symptoms. The
hernia is not acutely inflamed ; the patient is not greatly
distressed ; he flatters himself that he is better, and the
similar flattery of his friends is yet stronger : all are averse
from operation, and you can hardly persuade yourself to
be resolute about it. But there should be no hesitation.
I lost the chance of saving this man's life, by under-
estimating the importance of occasional vomiting as a
signal for operation. If you lose such chances, you will
be still more blameworthy ; for you will have had more
warning than ever I had.
And once more ; do not be deceived by the cessation
of vomiting in the extreme condition of strangulated
hernia. This sometimes happens ; but it is a token of
evil rather than of good, if general improvement do not
coincide with the cessation of vomiting. So, again, sick-
ness may be stopped by narcotism ; but here again there
is no evidence of such general improvement as might
justify waiting.
In the recent stages of strangulation, if it be not
very acute, the respiration and pulse are little affected.
The pulse is usually accelerated, and at first may be full
and firm. I find that it was between 80 and 90 in a
large majority of the ordinary cases which I have re-
corded ; and the respirations are, generally, I think, in
due proportion to the pulse. As the other signs of
strangulation become more marked, these, I think, always
I 2
/
ii6 ON STRANGULATED HERNIA,
coincide with them. The pulse usually becomes quicker,
feebler, smaller, unless indeed after the warm bath, when
its strength and size may be greatly increased ; the
^^ i-^^espiration, I think, keeps pace with the pulse.
Thus, these signs corroborate the others in urging to
an operation. I have not any notes or knowledge of
cases in which the pulse or respiration was so inconsistent
with other signs of strangulation as either to justify or to
forbid the operation. But you may have this for a safe
rule ; that if, while you are watching a case, doubtful
whether there be strangulation, the pulse and breathing
should increase in frequency, you may believe that there
is a commensurate increase in the reasons for operating.
Lastly, as to the patient's aspect and general condi-
tion, little that is definite can be said. You read of an
anxious expression, and it is called characteristic, as many
other fallacious things are. I should rather call it an
expression of distress or of misery ; but, however you
may name it, be careful not to think that you must see it
before deciding that it is right to operate for a strangulated
hernia. The worse a patient looks or feels ; the more he
looks shrunken, worn, and old-aged ; the more miserable
his sensations ; the more is it unlikely that his strangulated
hernia will be reduced without operation. But the
reverse is not true. I have operated with full right, as
proved by the result, on patients who neither looked nor
felt miserable or anxious in any sense of the word. And
I have seen a patient looking well and tranquil in
whom a femoral hernia, after seven days' strangulation,
contained completely gangrenous intestine.
ON STRANGULATED HERNIA, 117
LECTUEE 11.
In the last lecture, I tried to show how the signs of a
hernia supposed to be strangulated may be used for
guidance in determining whether its reduction must be
achieved by operation, or whether any simpler means for
reduction may be used. In this lecture, I will speak of
the trials at reduction that may be made, or may not be
made, before operating.
For a general rule, your first examination of a patient
with a hernia supposed to be strangulated should not be
with a design to reduce it at once, but rather with a
design to make-out what shall be done ; what are the
chances of reduction without operation ; what helps shall
be used to obtain it, if it be deemed desirable. Of course
you may reduce the hernia, if reduction at once be easy ;
but do not go on trying if it be difficult. If the case be
a bad one, you must first decide whether reduction with-
out operation should be even attempted ; and, if the
attempt is to be made, what and how much it should be.
For this decision, here are some general rules, which I
find illustrated by my cases.
In very bad cases — as, for instance, when the patient
vomits fsecal matter and has peritonitis^ or is in collapse,
with a small rapid pulse, hiccough, or other such extreme
signs — there should be no attempt at reduction without
operation. The risk of the operation is trivial in com
1 Note XI.
J ^
Il8 ON STRANGULATED HERNIA,
parison "with tliat of I'eturning sloughing or ulcerating
intestine into the abdominal cavity.
When the coverings of the hernia are so inflamed as
to make it probable that sloughing or suppuration has
taken place beneath them, reduction without operation
\ should not be attempted ; and, even when they are less
inflamed, none but very brief and very gentle eflbrts should
be made, for success is improbable, and failure may be
mischievous.
The longer the signs of strangulation have existed, the
shorter should be the efforts at reduction ; and the more
acute the signs are or have been, the more gentle should
these efforts be. Only, here, do not reckon among the
acute signs the intensity of pain in recent or greatly
enlarged hernia3 ; for many of the most intensely painful
herniag are reducible with the help of anaesthesia, though
they may need as much force as is in any case justifiable.
The longer and the more numerous and forcible the
efforts at reduction made, in any case, before it comes
under your care, the briefer and gentler should your own
efforts be ; if, indeed, you do not at once decide that
enougli has been done, and tliat there remains no fair
chance of reduction without operation.
If you find that you have to do with a hernia which
has been habitually irreducible, and in wliicli you have
reason to believe that, without any addition to them,
the contents of tlie sac have become strangulated, you
had better operate at once. You are not likely to
reduce a protrusion which even before strangulation was
irreducible.
Let me now suppose tliat, observing tliese rules, a first
examination of a strangulated hernia leads to the decision
MEANS FOR REDUCTION. 09
that its reduction without operation is to be attempted :
I cannot give a single rule of practice that shall always
suffice for the next step after such a decision ; but,
speaking generally, and of a great majority of cases which
come under treatment, it is a safe rule of practice that,
after a very warm bath and a few hours' rest in bed — say
from three to twelve hours, according to the case — a
single attempt at reduction, of reasonable force and
length, should be made ; that, if this should fail, chloro-
form or ether should be given ; that then, in some cases,
but not in all, a second attempt should be made ; and
that, if this should fail, or if it should not be made, the
operation should be performed while the patient is still
insensible.
The hot bath should be used in all cases that are not
very bad, unless in old and feeble persons, whom it might
depress too much. Among these, its place may be supplied
by very hot fomentations, or by warm poultices over the
hernia and the parts near it ; and these must be used as
the next best things when a hot bath cannot be had.
Helped by rest, all these things are certainly very useful,
whether by relieving the tendency to irritable muscular
action, or by reheving congestion, or by whatever otlier
means. Especially you may see their utility in hospital
patients, who are commonly brought-in wretched, chilled,
and restless, with their hernise tense, full and very pain-
ful, and their abdominal muscles startinsj into resistance
at the least painful pressure. The heat of the bath,
and bed, and recumbent rest, may remedy all this ; and
the hernia may become easily reducible, or may even
reduce itself. It is commonly advised to have the bath
so hot, and to keep the patient so long in it, that he may
I20 ON STRANGULATED HERNIA.
be very faint ; and during this faintness to attempt the
reduction while the patient is still in the bath. I more
than doubt the prudence of this advice. It seems to me
better to let the patient be simply soothed and relaxed in
the bath, then to put him into bed wrapped in warm
blankets, lying on his side, on his back with his knees
drawn-up, or with his pelvis a little raised, and then, after
an hour or two of complete rest, to attempt the reduction.
The advantage of this plan is shown in the many cases in
which the surgeon gets the credit for reducing a hernia
which the house-surgeon has failed to reduce. The
house-surgeon tries in the bath, and fails ; the surgeon, an
hour or two later, succeeds, not, or at least not always,
by greater skill, but by reason of the more favourable
condition of the patient after a time of rest and warmth,
and of his better position — lying flat instead of half-sitting
as in the bath. This employment of rest and the bath
may be helped by opium whenever the hernia is very
painful, and the patient too restless to have a chance of
natural sleep. A grain of opium may procure the rest
necessary for the quietude of the parts, but is less likely
to be useful with femoral than with umbilical hernias, and
less likely with these than with inguinal.
In the old, and in others who may have had inactive
bowels long before the strangulation, and in whom fsecal
accumulations or abundant air may be in the large intestine,
an enema even of a large quantity of liquid should be
used ; for the emptying of the large intestine may greatly
facilitate tlie return of tlie hernia. Purgatives, I believe,
had better not l:)c thonght-of, if there be any marked
siccus of strangulation. There are no clear indications for
MODE OF REDUCTION. I2i
determining the cases in which they might possibly be
useful ; and, if they do no good, they may do grievous
harm. I do not doubt that some have gained advantage
from purgatives ; but in my notes and memory I find
several instances of mischief, and no cases in which
there seemed reason to think that the patients were the
worse for not taking any sort of purgatives after evidence
of strangulation.
After the warm bath and rest — and still speaking of
only the majority of cases, for in some there is no time
for these things — you may give chloroform or some other
anaesthetic, and try to reduce the hernia. How you are
to do this, I cannot tell you now ; nor what time and
force are reasonable to be used. You must imitate what
you see done by men of repute, and use the best common
sense you can. I can tell you some things that you must
not do. You must not go to work as if you were re-
solved to reduce the hernia 'per fas aut nefas ; you are
not to spend an hour or even half an hour about it, or
use all your force, or take off your coat and turn up your
shirt-sleeves, or kneel on the bed that you may press with
the more weight ; you are not to let half a dozen persons
try their hands in turn. You are not to do these or the
like things, all of which I have known as the sources of
dire calamities. You are to be gentle and self-restraining,
mindful of the delicacy of some of the structures you are
handhng, and that you may do them much more harm
than would come of the operation which you are trying
to avert. These cautions are the more necessary because,
when the patient is insensible, you have nothing but
your own sense and senses to tell you how far you may
6./->o
122 ON STRANGULATED HERNIA.
go without doing liarm. The great vakie of chloroform
and ether is that, by abohshing sensation, they put an end
to the muscular resistance to reduction which, whether
he will or no, the patient makes when hurt by the pressure
of his hernia. Hence they are most useful in the hernias
of which the difficulty of reduction is chiefly due to
muscular resistance ; in the recent, or in the recently
much enlarged ; in the inguinal more than in the femoral,
and in these more than in the umbilical ; in the painful
more than in the painless. Chloroform and ether are by
so much the most potent helps to the reduction of hernias,
that it may seem as if it would be right to use one of
them without waiting for the influence of a warm bath,
or recumbency, or any similar means. Sometimes it is
right thus to do, especially in hernias that have only
recently come down and are intensely painful. But
more commonly, if there would be danger in waiting for
three or four hours, it is because strangulation is so far
advanced that the operation ought to be done at once,
without any previous attempts at reduction. If there be
no such extreme urgency for immediate reduction, there
can be nothing but advantage in the use of the bath and
the tliree or four hours' rest in bed ; for they may make
the hernia reducible, or, even if they fail of this, they may
cause changes in it which are beneflcial for botli the per-
formance of the operation and for tlie probabilities of
recovery after it.
I have been speaking lately of tlie plans for average
or medium cases ; and before, of the cases in which no
attempt at reduction witliout operation should be made.
You may ask. Are tliere any cases in wliich it is justifiable
REDUCTION. 123
to wait longer after the warm bath and rest and chloro-
form and a fair attempt at reduction have been tried
and have failed ? I will not venture to say that such a
case for waiting cannot happen ; but I am clear that
the rule, with barely an exception, must be that, when
you are satisfied that a hernia is strangulated, and you
have failed to reduce it with such helps as I have indi-
cated, you should operate. While the patient is still
insensible the operation should be done ; and you
should prepare for it before giving an ansesthetic. Of
course, if you are satisfied that the hernia, though irre-
ducible, is not strangulated, you may wait ; but in this
case you must watch almost impatiently, for an intestine
or omentum that cannot be reduced is very likely soon to
become strangulated, and so is one that is inflamed or
blocked-up in a hernial sac. Still, if no signs of strangu-
tion, especially if no vomiting, should supervene, you
may wait from day to day ; but if the signs do occur,
especially if there arise vomiting, or increase of pain, or
increasing rapidity of pulse and breathing, then you must
operate at once, and you had better not try again at
reduction. The trial is much more likely to do harm
than to do good : you had better operate at once. No-
thing does more harm to a strangulated or nearly strangu-
lated hernia than the force of an unsuccessful attempt at
reduction.
While you are waiting, you may use, in different cases,
ice ^ or warm dressings, enemata, aperients, or opiates. I
^ There are strong authorities in favour of the use of ice or other cold appli-
cations over large hernise: — Lawrence, 'Treatise on Hernia,' 5th edit,, p. 1(37;
Teale, 'Abdominal Hernia,' 1846, p. 104; Erichsen, 'Science and Art of
Surgery,' 5th edit., vol. ii., p. 449; Haward, 'St. Geo. Hosp. Eeports,'
vol. i., p. li^5; Birkett 'Holmes's Syst. Surg.,' 2nd edit., vol. iv., p. OOU.
124 ON STRANGULATED HERNIA.
cannot tell you the indications for each of them. I have
not had sufficient experience of waiting to have weighed
the several vahies of these things. But there are at least
one or two conditions favourable for all cases in which
you desire to wait ; namely, rest in bed and very sparing
food. Nothing should be allowed to disturb the patient's
rest, and no handling of the hernia should be permitted.
Part of the value of ice and poultices and other like
applications is this, that they all keep hands o^}
Of other supposed helps I will not speak — of tobacco,
and curious postures, and shakings with the legs up and the
head down, and cupping glasses, and other like and unlike
things. They are ingenious wrong-doings, more dangerous
than the operation which they are intended to avert.
In speaking of hernise as being reducible, I have had
in mind only such as can be completely and certainly
reduced. But it is not uncommon to meet with cases of
strangulated hernia, in which the reduction is doubtful or
partial. As I looked through my cases, I found many of
these recorded, in which there was delay in sending
patients to the hospital, because surgeons believed that
part of the hernia was put back, and hoped that the rest
would soon go ; and some in which, even in the hospital,
there was mischievous delay through the same fallacious
hope. It is not easy to say what takes place in these
partial or doubtful reductions. Some patients will tell
you that the whole never did go back, and that what now
seemed to be reduced might only be an additional pro-
trusion. Sometimes, I think, air is pushed back from the
intestine, or fluid from the sac ; sometimes omentum is
» Note XII.
INCOMPLETE REDUCTION. 125
put back ; sometimes, perhaps, part of the intestine ;
sometimes nothing — the whole notion of reduction being
fallacious. The liability to deception is greater than you
would imagine. You may feel a thrill of receding fluid,
or a gurgling of air, which you may suppose to be what
some describe as the characteristic gurgling (as if any-
thing of the kind were infallibly characteristic), or some-
thing slipping back ; but all may be fallacious. There is
one practical rule for all these cases. If the symptoms of
strangulation be not relieved by the supposed reduction ;
if the vomiting continue, or the pain, or the patient's
sense of distress, or any other of the distinctive symptoms
— then, without delay, you must operate. A partial
reduction of a strangulated hernia, if it be not followed
by a complete relief of symptoms, is in nothing better
than no reduction.
I may add that most doubtful reductions are not
reductions ; and of the partial reductions, none are safe
except some of those in which intestine is put back and
only omentum remains in the sac.
Be prepared also for cases in which reduction is, or
seems, complete, and yet the signs of strangulation are
not relieved. In these, a hernia may be returned en
masse^ or pushed into another sac, or between the perito-
neum and fascia ; or the case may be one of hernia com-
phcated with an internal strangulation, or one of many
other conditions so hard to discriminate and deal with,
that I can give only one general rule for their manage-
ment— viz., if you can feel a lump at or near the
hernial ring, as if there were something which may be a
strangulated hernia, then you must operate.
126 ON STRANGULATED HERNIA.
To end what I should say respecting the propriety of
operating, I ought perhaps to speak of the condition of
the patient*as affecting the risk of the operation, by reason
of age and general health and various complications.
Among my cases, I find not only many of the fattest
and feeblest, but examples of complications with phthisis,
acute and chronic bronchitis, aortic constriction, phlebitis,
gastric ulcer, diseased bladder, intestinal disorders of
various kinds, and internal strangulation. Patients such
as these one would not w^ound for any trivial good ;
but, with a strangulated hernia, the peril of doing the
operation can hardly ever be so great as the peril of
leaving it undone. Old age and feebleness, fatness, in-
temperance, or unsoundness of whatever kind, may add
to the risks of this, as of any other operation ; but all these
risks must be accepted. A patient must not be allowed
to die with a strangulated hernia, if by any means whatever
the strangulation can be relieved ; and you must not be
averted from the operation by any consideration of the
number of deaths that follow it. The deaths after the
operation may be 50 per cent., but the deaths due to the
operation are not more than 5 per cent., and even these
would, probably, have been deaths from the hernia if
the operation had not been performed. The great pro-
])ortion of deaths is made up of those in whom the stran-
gulation lias done mischief which the operation cannot
remedy. It is not unfair to maintain that, speaking
generally, the deatlis after operations for hernia are only
to be counted as fiiliircs to save life, while the recoveries
are to be counted as lives saved from certainly impending
death.
ON STRANGULATED HERNIA. 127
LECTUEE III.
The design of the operation for hernia is to divide the
structures which tightly gird the protruded parts, so that
these may be returned. These structures, forming what
is called the stricture, are in some cases outside the hernial
sac ; in some, in its very substance ; and, according to
these and other differences, the operation may in some
cases be completed without opening the sac, and in other
cases must include this opening. The advantages of the
two methods have been often discussed, and I may begin
by speaking of them.
There can be no doubt, I tliink, that if all the rest of
the operation were always the same, the advantage of
reducing the hernia without opening the sac ^ should always
be sought. Thus to reduce a hernia is the next best thing
to reducing one without any operation at all. The struc-
tures divided externally to the sac are insignificant, and it
might be difficult to name an operation less endangering
either life or health than this would be. The peritoneum
is not wounded ; the intestine and omentum are not
touched or exposed to air ; the wound may be small ;
any haemorrhage may be easily stayed and must be all
external. Thus the wound is favourable for speedy
healing, and erysipelas or any other mischief is not likely
to extend to the peritoneum.
These are sufficient reasons for always wishing and
1 Note XIII,
128 ON STRANGULATED HERNIA.
generally intending to operate without opening the sac,
especially in old and feeble people and in cases of large
hernise. But you must not let your wishes carry you
too far. They may lead you into great mischief. For,
first, there are many cases in which the contents of the
sac are not fit to be returned into the abdomen — for
instance, when they are sloughing, or deeply ulcerated, or
strangulated within the sac. The risk of returning these
is so much greater than that of opening the sac, that you
should not hesitate to open it whenever you have any,
even slight, reason to suspect any of these conditions of
the sac's contents. And such suspicion there must always
be in these sets of cases — 1, in those in which the stran-
gulation has existed long, say four or more days, whether
with slight or with severe symptoms ; 2, those, of what-
ever date, in which the signs of strangulation are very
acute ; 3, those in which there are very marked signs of
advanced or low inflammation in and about the sac ;
4, those in which the contents do not go back easily and
within two or three minutes after all stricture is fairly re-
lieved. And in measuring this ease of going back, you
must be scrupulous ; for I have certainly done harm, and
seen more done, by trying too long to reduce hernias
without opening the sac — fingering and clearing the parts,
and pressing them many times ; damaging intestine, and
exciting suppurative inflammation all about the sac ; so
that when, at last, the operation was completed, much
more mischief had been done than if the sac had been at
first straightforwardly opened.
I think, then, you may take this as a safe rule in all
ordinary cases : intend to complete the operation without
OPERATION. 129
openiiig the sac, but give up your intention if you find
any reason to suspect complications, or very morbid states
of the parts within the sac, or any such difficulties as
would lead to the use of forcible or long continued efforts
at reduction. Of course, the more you practise the
operation, the less frequently will these difficulties hinder
you ; but you may keep to the same rule, and think it
w^iser to avoid difficulties than at all cost to overcome
them. And finally, when you are in doubt, open the
sac; for though the advantages are,, on the whole,
clearly in favour of not opening the sac, yet the amount
of advantage is not so great as to justify any considerable
risk for it. Eough statistics of operations are not to be
taken as measures of this advantage. In all the worst
cases the sac must be opened ; and, of these, a large pro-
portion will die whatever be the manner of the operation.
As to the method of operating, there are many, and
some good, anatomical rules on which I shall not touch.
They are admirably laid down in " Lawrence on Hernia!'
I will only give some general rules, such as may be useful
in nearly all cases.
In all, you should decide at first, if possible, where-
abouts the stricture is, so that your first incision may be
fairly over it, and give you room to act on it without
needless length of cutting. In femoral hernia, you may
be sure that the stricture is at, or within half an inch of,
the femoral ring ; and this is near enough for guidance for
the first incision. In umbihcal hernia, the mouth of
the sac is always the seat of the stricture ; and the middle
of your first incision may be right over it. In inguinal
hernia, the stricture is, in the large majority of cases, at
K
I30 ON STRANGULATED HERNIA.
or within the internal inguinal ring ; and the incision
should extend from the internal ring to beyond the
external ring, and (according to the characters of the
hernia) to a greater or less distance towards or along the
scrotum. But, in inguinal hernia, the stricture may be
at the external ring, or, being formed by the thickened
mouth of the sac, may be pushed up towards the ab-
dominal cavity, or down along the canal, or beyond the
external ring to some distance in the scrotum. Moreover,
in some rare cases of congenital hernia, there may be two
strictures — one at each end of the open canalis vaginalis.
For these cases, it is useful to apply a rule devised, I
think, by Mr. Luke, for ascertaining the seat of stricture ;
namely, to observe at what point along the course of the
hernia the impulse on coughing ceases. For, when a
hernia is strangulated, the impulse can be felt as far as
the stricture ; beyond that, it cannot be felt : therefore,
where the impulse ceases, there probably is the stricture ;
and this part must be fairly included within the length
of your incision.
In femoral hernia, your first incision may be vertical,
ill a line drawn straight down from the spine of the
])ubes — a projection which you can always easily feel.
This incision seldom needs to be more than an inch and
a half long, and may sometimes be less. In umbilical
hernia, a vertical incision of an inch and a half or two
inches will suffice, in the middle line, so as to reach
eitlier the upper or the lower border of the mouth of the
sac. But I am disposed to believe, though I have not
tried it, that in Inrgc umbilical hernia3, two incisions,
going to oi)}>osite borders of the ring, would be better
OPERATION. 131
than any one. In inguinal hernia, the incision should
take the direction of the neck and upper part of the
hernia, and its length must vary according to the size of
the parts to be returned.
Through these incisions you must go on and on,
through the several layers which your anatomical dissec-
tions of healthy parts will sometimes enable you to
recognise, till you come to the sac. The thickness of
these layers is more various than you may suppose.
Especially in small femoral herniae, you will often find
an unexpected quantity of fat about the sac ; and in
umbihcal hernise, verv much more fat about the mouth
of the sac than the thinness of the integument over it
would at first suggest.
Through whatever thickness, you must continue
cutting in the same direction ; and when you are fairly
on the surface of the sac, keep to the same line. Do not
clean the front of the surface of the sac ; do not separate
it from the surrounding textures. No good can come of
this, but much harm may. You want nothing more than
a linear division of the stricture, whether with or without
a linear opening of the sac. All that is done on either
side of this line is useless or mischievous.
When you have thus fairly reached the sac, and have
exposed its neck and mouth or narrowest part, you must
proceed difierently accordingly as you propose to com-
plete the operation without or with an opening of the
sac. In the latter case, you open the sac first near its
mouth, and then along the length and full extent of your
external incision, and then divide the stricture from
within. You may do this on your finger-nail or a
132 ON STRANGULATED HERNIA.
director, and with cares about the intestine and other
structures which are insisted on in all handbooks. In
the former case, when you intend not to open the sac,
you must find where the stricture is, and divide it outside
the sac.
Among femoral hernise, there are differences as to the
seat of stricture which I cannot explain to you, but
which my cases made very clear to me. In some in-
stances, as you trace up the neck of the sac, you find it
tightly banded across by the layer of fibrous tissue called
Hey's ligament — a layer traceable as a falciform edge of
the fascia lata, where that fascia, bounding the upper part
of the saphenous opening, is connected with the crural
arch, and is thence continued to Gimbernat's ligament.
Sometimes a fair division of this layer of fibres up to
the edge of the crural arch is sufficient to render the
hernia reducible ; and here, with the reduction, should
end the operation. But, in more cases, this is not suffi-
cient ; and you may feel the stricture formed by bands
of fibres which encircle the neck of the sac, and which
must be divided, band by band and layer by layer, till
none can be felt. These fibres are part of the deep
crural arch, beneath which the hernia has protruded.
Very rarely, however, even the division of these is not
sufficient ; for the stricture is formed by thickening of
the moutli of the sac itself. This condition, which is a
common cause of stricture in inguinal hernia, is very rare
in femoral ; but it certainly does occur ; and, in any case
well suited fur the o])eration without opening the sac,
you may try to thin the mouth of the sac without open-
ing it, and thus to make it extensible enough for the
OPERATION. 133
return of its contents. You may try this ; but the
chances of success are small. You are much more likely
to cut into the sac at some thin place ; and, when you
have done this, you had better enlarge the opening and
divide the stricture from within.
It is this uncertainty as to the exact seat of stricture
in strangulated femoral hernia, which makes it advisable
to put-on a strong resolve not to use too much time or
force in endeavouring to operate without opening the sac.
You will be apt to think, when you have divided one
thing, that now you will be successful ; and you try to
press-back the bowel. But you fail ; and then you
divide something else, and try again ; and now again
you fail. And thus you may go-on, till you have done
more harm than you would have done by a straightforward
opening of the sac and immediate easy division of its
stricture and return of its contents. Keep this in mind ;
that an easy reduction from an open sac is better than a
difficult reduction from a closed one.
In umbilical hernia, the case is simpler. The stricture
is always in the tough fibrous tissue of the sheath of the
rectus. When you have reached this, commonly going
much deeper through fat than you expected, and not
only deeper, but further under the sac, you may be able
to divide the stricture without opening the sac ; but this
is difficult, for the sac is always very thin, and there may
be little tissue between it and the fibrous ring. Still it
is well to try, but not too long. You are more likely to
open the sac at or close by the stricture ; and, if you do
this at all, you may as well save time and force by open-
ing it more widely. .
134 ON STRANGULATED HERNIA.
In inguinal hernia, the stricture is in many cases, and
was in the majority of those on which I operated, formed
by the mouth of the sac, thickened and hardened by
what appears to have been an inflammatory process,
producing a scar-like and contracting tissue. This tissue
forms a band about a fourth or a third of an inch in width,
and about a line in thickness, and sometimes has a thin
sharp inner edge. By the way, let me say that the
formation of this band is not the result of wearing trusses.
I have seen it very marked in patients who never wore
a truss ; and I have seen the sac thin and soft in every
part in those by whom trusses have been long worn.
But, however it may be formed, this annular thickening
and contraction of the mouth of an inguinal hernial sac
is a common cause of stricture. On account of it, you
should proceed at once to expose the mouth of the sac ;
unless, indeed, you should have found the tissues outside
it so tight that you may fairly believe the division of
them will be sufficient for permitting the reduction of
the hernia. When you have exposed the outside of the
thickened mouth of the sac, you may still achieve the
reduction without opening, by gradually thinning the
mouth — dissecting-off band after band from any portion
of it. Sometimes the mouth will yield sufficiently at a
part thus tliirmcd to stretch and allow the reduction ;
but more often, I tliink, you will fail, and will have to
open the sac and divide the stricture from within.
Here, as with femoral hernia, be scrupulous not to
spend more than fair force and time for the sake of the
reduction without opening the sac. It is a good thing
to succeed; a very bad thing to fail. You must measure
OPERATION— FLUID IN SAC. 135
how much risk of harm it is right to incur for the hope of
doing good.
If the reduction be accomphshed without opening the
sac, you will have attained the best immediate object of
the operation ; but remember that fallacies of reduction
are possible here as well as in the cases in which no
operation has been done ; they are, however, less mis-
chievous, for, if the stricture be completely divided, there
will be no strangulation of whatever remains in the sac.
Especially you may have no fear if, as commonly happens,
after returning intestine, some omentum remain in the
sac. This will do no harm ; but if more than omentum
have remained in the sac, and the signs of strangulation
be not relieved or lessened, you must operate again and
open the sac, regarding these cases in the same light as
those of partial or doubtful reduction, of which I spoke
in the last lecture.
But suppose the sac opened, as it should be in nearly
all bad cases, and in many which, though they are not bad,
yet may be called difficult, here may occur the most diffi-
cult question of all. What is to be done with the contents
of the sac? Of course, in most cases you are to return
them ; but in many you are not ; and which are which ?
Look first to the character of the fluid which, in most
cases, you will let-out of the sac. In most cases, not in
all ; for, in some small femoral hernias, especially in very
thin dry people, and in many umbilical hernise, and in
any that contain a large quantity of omentum, there may
be no fluid, or too little to be distinctly seen. But if there
be enough to judge from, you may deem it a good sign
if the fluid is clear, and yellowish like serum, or, rather.
136 ON STRANGULATED HERNIA.
like liquor sanguinis — for it will coagulate spontaneously.
This indicates only such an exudation of fluid as may come
from a simply congested piece of intestine, or from a piece
not badly inflamed ; and the cases would be rare, if there
can be any, in which ' intestine found behind fluid such
as this might not be returned. The same may be said
when with fluid such as this there are flakes or bands of
lymph or fibrinous exudation ; for these tell of only such
inflammation as may safely be recovered from when the
intestine is returned. I am disposed to say the same of
the cases in which the fluid is clear, but more or less
deeply blood-stained ; for this exudation of blood-cells or
blood-colour is not characteristic of any serious morbid
change in either the sac or its contents. But when the
fluid of the sac is turbid, brownish, muddy, it tells of
more advanced changes in the intestine or in the omen-
tum ; and the further it goes in this direction the more
carefully must you consider whether these are in a fit
state to be retiurned. You will probably have to decide
that they are not fit, when the fluid has a distinct faical or
putrid odour ; and of course they are not fit when the
fluid has faecal matter mixed with it.
I do not venture to say that the characters of the fluid
contents of the sac of a strangulated hernia are to be ab-
solutely relied-on as guides for practice ; but they are
good evidence to be taken into the general account, for
they fiiirly represent tlie state of mere congestion or in-
flammation, or more or less advanced decay or decomposi-
tion, or giving-way of tlic walls of strangulated intestine
and omentum.
Not rarely, when you have divided the stricture and
OPERA TION— OMENTUM, 1 37
returned the contents of the sac, fluid runs from the
peritoneal cavity. I do not know any rule of practice
but that you must let it run as long as it will, and, if it be
of very unsound appearance, not close the wound till the
fluid has ceased to flow, if even then.
As to the omentum which the sac may contain, and
what to do with it : if there be a small quantity — say two
or three square inches — and this be not adherent, and
not more changed than by congestion or slight inflamma-
tion, there can be no question that you are to return it
after the intestine ; and if there be a piece of even very
large size, and not more changed in texture, you had
better return it if you can without much force or expense
of time. But it sometimes happens, when the abdomen
is tense with over-filled intestine, that you cannot return a
large piece of omentum without much difficulty. Wliat
then? Shall you cut it off" or leave it in the sac ? I advise
you to leave it. I believe that the cutting-ofl", with the
necessary ligatures or other fastenings of vessels, adds to
the dangers to life ; while the leaving of omentum is only
sometimes followed by greater diflBculty in the fitting of a
truss — a difficulty which is not great enough to justify any
risk of life.
Still more may this rule of leaving omentum in the sac
be observed when a large piece of it is hardened and
thickened as by old disease. When a small piece is thus
changed you may, I believe, return it.
When omentum is adherent to the sac, but in other
respects fit to be returned, you should break the ad-
hesions and return it, after stopping all bleeding. If it
be not fit to be returned, leave the adhesions; and in
138 ON STRANGULATED HERNIA.
any case do not break adhesions so near the mouth of the
sac that their vessels are hkely to bleed into the abdominal
cavity.
When omentum is sloughing, or nearly sloughing, leave
it, that it may cast its sloughs out.
But the chief questions in these operations are con-
cerned with the state of the strangulated intestine and the
manner of dealing with it. You are to judge chiefly from
the colour and the tenacity. Use your eyes and your
fingers ; sometimes yoiu: nose ; very seldom your ears, for
what you may be told about time of strangulation, sensa-
tions, and the rest, is as likely to mislead you as to guide
aright.
As to colour, any tint, from the natural grey through
various shades of rosy or ruddy pink, or redness, up to
the deepest crimson, even verging on blackness, may be
consistent with fitness for returning of the intestine, if the
texture be good. All these tints may be due to conges-
tion and stagnation of blood, or to extravasation of blood
into the intestinal walls ; and all these may have been
without such inflammation as would spoil the texture of
the intestine, and may not have endured long enough to
kill it. I am disposed to say that you may return intes-
tine of any colour short of black, if its texture be good ;
if it feel tense, elastic, well filled-out, and resilient, not
collapsed or sticky ; and the more the surface of the in-
testine shines and glistens, the more sure you may be of
this rule.
When a piece of intestine is thoroughly black, I believe
you had better not return it, unless you can be sure that
the blackness is wholly from extravasated blood. It may
GANGRENOUS INTESTINE. 139
not yet be dead, but it is not likely to recover ; and, even if
it should not die after being returned, there will be the
great risk of its remaining unfit to propel its contents, and
helping to bring on death by what appears very frequent
—distension and paralysis of the canal above it. But,
indeed, utter blackness of strangulated intestine commonly
tells of gangrene already ; and of this you may be sure if
the black textures are lustreless, soft, flaccid, or viscid,
sticking to the fingers or looking villous. Intestine in this
state should never be returned.
Colours about which there can be as little doubt, for
signs of gangrene, are white, grey, and green, all dull,
lustreless, in blotches or complete over the whole pro-
truded intestine. I cannot tell why there should be so
many colours in different cases, or sometimes even in the
same case ; but all are alike certain signs of gangrene,
and they are always combined with loss of due tone
and texture of the intestinal wall. Intestine with these
marks, even though they be small, must not be re-
turned.
Then, as to the texture of the protruded intestine : it
should be, for safety of return, thin-walled, firm, tense,
and elastic, preserving its cylindrical form, smooth,
sUppery, and glossy. The further the intestine deviates
from these characters, the more it loses it gloss and looks
villous, the more it feels sticky, and is collapsed and out
of the cylinder-form, the softer and more yielding, the
more pulpy, or like wet leather or soaked paper, the less
it is fit for return. And when these characters are
combined with such bad colours as I have described, the
intestine must be taken to have perished, and had better
140 ON STRANGULATED HERNIA.
be laid open, tliat its contents may escape externally and
do no harm.
But, short of gangrene, there may be ulceration of the
walls of the intestine. The usual place for this is where
the intestine is girt by the mouth of the sac, and it is
most frequent in femoral hernia3 long strangulated. In
these it is especially the sharp hard edge of Gimbernat's
ligament which seems to cut into the intestine, thinning
its wall and at last piercing it : and the chance of this
having happened is enough to justify the rule that, where
the strangulation has been sharp and long, the intestine
should be gently drawn-down after the stricture is
divided, in order to see that there is no great injury of its
walls where the chief pressure of the stricture has fallen
on them.
Here, too, because they are similarly dangerous to life,
I might speak of laceration of the intestine in too violent
attempts at reduction, or wound of it in operation ; but I
have no personal experience of such cases, and can add
nothing to what you may read in the best treatises on
hernia — such as that of Sir William Lawrence, or in the
chapters devoted to hernia by Mr. Erichsen in his Science
and Art of Surgery^ or by Mr. Birkett in Holmes's System
of Surgery. These will supply you not only with their
authors' experience, but with what tliey have gathered
and set in order from tlie writin^^^s of others. Limitinir
myself to what I have studied in my own cases, I must
omit many things ])esidcs ruptured and wounded intes-
tine ; such as the various complications of strangulated
hernia with hydrocele and misplaced testicle, with vari-
cocele, and with accidents of the operation, such as
OPERATION. 141
haemorrhage from the epigastric or the obturator artery.
Some of these things I have never seen ; others I have
seen only once or twice, and have learned concerning them
nothing but what you may learn by reading the works to
which I have referred you.
But, as to the treatment of sloughing and ulcerated
intestine of which I was just speaking, I will only say that
it has always seemed to me more prudent to incur a great
risk of having a permanent external faecal discharge by
leaving the intestine at the wound, than to add to the risk
of life by returning any thing which it may seem possible
to repair by suture or any such means. Of course, these
means are not to be thought-of if the sloughing or
ulceration be of more than very small extent ; but even
in the smallest, unless in some very rare cases, I would
not add to the inevitable risk of life by returning the
damaged intestine. In cases of hernia, the saving of life
is so much more important than anything else, that we
ought not to incur a risk of life for anything less than the
highest probabihty of saving a patient from some life-long
distress.
142 ON STRANGULATED HERNIA.
LECTURE lY.
The former lectures have related to the diagnosis of
strangulation of a hernia, and to the operation necessary for
its relief. This last will be on the treatment of cases after
operation. In looking over my notes of hernia for illustra-
tion of this matter of after-treatment, I was struck with the
great difference between the practice of late years and that
of thirty or more years ago. In reference to all the subjects
of the preceding lectures — the discrimination of the cases
needing operation, the modes of operating, and generally,
the pathology of strangulated hernia — knowledge has, we
may believe, increased, but without any material change of
opinion ; but, when we come to questions about treatment
of patients after operation, we seem to know, and
certainly we believe, things widely different from those
which were geiierally believed when I was a student.
The present general rule of practice after operation,
in cases likely to go on well, is to do what is called
nothing ; to wait till some reason for interference is
manifest ; and, while waiting, to take care that the patient
shall have fit bedding, fit air, fit food, quietude, and good
nursing. All these prime conditions of health are called
' nothiiiGf.' The contrasted ' sometliiiiir ' would be bleed-
ing, active purging, or other restless interference with the
natural course of recovery, such as w^is in vogue in the
earlier years of my case-taking, and such as had not quite
TREATMENT AFTER OPERATION. 143
ceased twenty-five years ago, when I became assistant-
surgeon to the hospitaL In this contrast you will see
only an illustration of the great change of opinion
respecting treatment which may be observed in a wide
range of medical practice, as in cases of fever, acute
rheumatism, pneumonia, and all acute inflammations — a
change shown, not by substituting one remedy for another,
but by letting many diseases and the effects of many
injuries take their natural course, in the confidence that
they will come to a natural good end, and that we
have no medicines potent to alleviate or cure them. But
let me say that, while I have no doubt that the present
general plans of treatment are better than the past, I yet
do not believe that the past plans were so mischievous as
some have told of them. I have no recollection of serious
harm being often done by bleeding in the many cases of
illness, whether slight or severe, in which, during my
apprenticeship, I practised it. In a few cases I think it
was mischievous, but in the great majority it was harm-
less. In many, it gave such relief from pain or other
distress as naturally strengthened the belief that it did
real good ; and in a few cases I do not doubt that it was
beneficial. Still, in cases of strangulated hernia, whether
before or after operation, I think you never need bleed a
patient. I do not believe that bleeding ever saved the life
of a hernia-patient which, but for the bleeding, would have
been lost.
And as for purgatives, though I believe they were
often mischievous and more often unnecessary, yet I do not
doubt that they were, and still may be, sometimes very
useful ; and I wish I could tell you more exactly than I
144 ON STRANGULATED HERNIA,
can the class of cases in which they should be used. At
present, I know only one — the class, namely, in which it
IS clear that strangulation has occurred while the bowels
are overfilled, and in which the strangulation is acute and
quickly relieved.
Now for the general rules of treatment after operations
for strangulated hernia. Bear in mind the complicated
cases with which you may have to deal. In each case
there are, or may be, these constituents : the intestine
damaged by displacement and by being forcibly replaced ;
the operation -wound ; the effects of an anaesthetic ; the in-
testinal disorders which, at least in many cases, preceded
the strangulation, and may continue after the operation ;
the effects of aperients and other medicines given for this
previous disorder or for the strangulation ; the inflamma-
tion or worse than inflammation of the sac and its contents,
whicli does not subside immediately after even a successful
operation.
When a case has been timely operated on, all these
things may amount to nothing worse than may be left to
the course of spontaneous recovery ; and a case that goes-
on well requires that ' nothing ' in the way of treatment
of which I spoke just now. But, when anything goes amiss,
you must have in mind all the things I have enume-
rated, in your endeavour to interpret the signs of wrong
and to amend it. Very few cases are more difficult to
manage than those wliich do not go-on well after opera-
tion for hernia. There are terribly few which, having
gone out of the right course of recovery, can be brought
back to it.
What, now, are tlie signs of going-on well? Cliicfly
TREATMENT AFTER OPERATION. 145
a consciousness of complete relief ; that is, of relief not
only from the local distress, but from the general misery.
Deceptive as sensations often are, tiiis rarely is ; and, if a
patient be not conscious of relief, you must keep on the
alert, and suspect that something is wrong. Besides, there
should be no pain or acute fever. Mild traumatic fever
there may be ; but there should be no more ; no nausea
or sickness, but general quietude or sound sleep, a gradual
recovery of appetite and strength, and, after a time, action
of the bowels. I say, after a time, wishing to be indefi-
nite. Sometimes the bowels act very soon after the
operation, and this may be harmless ; but I think it is
not good, for it indicates either the effect of physic
wrongly given before the operation, or some irritation of
the bowels which would be better at rest.^ They do best
who, while relieved from their distress, have no action of
the bowels for some days. I know no necessary limit to
the quietude in which the bowels may be left. In one of
my cases, they did not act for nine days after the opera-
tion ; and I have heard of others where, without any dis-
advantage or discomfort, there was still longer inaction.
But this is, I think, a good general rule — to leave the
bowels at rest for four days after the operation ; then, if
all seem well (not otherwise), to order a simple enema ;
and if this be not sufficient, some aperient. I know no
advantage in leaving the bowels longer inactive than these
four days ; and I had one case in which great incon-
venience, to say the least, was occasioned by a very large
accumulation.
1 Note IV.
L
146 ON STRANGULATED HERNIA.
After the action of the bowels, if all still go on well,
there is no need of considering anything but the patient's
comfort ; and the local treatment and the diet may be of
the plainest kind. Excess is more likely to be mischievous
than spareness.
Among cases that do not go-on well, there is a great
variety ; but I shall speak of those alone in wdiich the
wrong is in something peculiar to hernia. Of course the
wound of the operation may lead to any of the evils that
may foUo^r otlier wounds, as erysipelas, pyaemia, and the
rest ; but these I shall almost pass by.
Amon^^ my cases, I find some in which ill-looking
symptoms, such as diarrhoea or colic followed the opera-
tion, but meant no serious mischief, being only the
continuation of the intestinal disturbance which preceded
the strangulation. I have already spoken of this matter ;
but it is worth repeating, that it is common for the
descent and strangulation of a hernia to be preceded by
some intestinal disturbance, the signs of which may be
suspended during the strangulation, and renewed after the
operation. Whatever the disturbance, it may be treated,
or left alone, as if no operation had been done ; but it must
not be forgotten in estimating the meaning of any sjniiptom
of ill-doing.
Of these symptoms, one of the chief is vomiting. If a
patient vomit once or twice soon after an operation for
liernia, it may only be because tlie stomach was filled with
secretions before tlie operation, and now finally empties
itself. In this is no harm — })erhaps some good. But, if
the vomiting coiilinue, it may be a sign of the gravest
import. It may, indeed, be due to chloroform or ether.
VOMITING AFTER OPERATION. 147
I have seen several instances of this, and among them one
in which'chloroform-sickness continued for three days after
the operation, endangering the patient's life. Generally
you may distinguish the vomiting due to chloroform from
that due to peritonitis or unrelieved strangulation, by its
being attended with horrible nausea, like sea-sickness ; by
its producing no f^cal fluicl or abundant gastric secretion,
there being more retching than vomiting ; and by the
patient's feeling relieved of his hernia, however wretched
he may feel with his nausea. If the pain and distress of
the hernia be relieved by the operation, and, except for
vomiting, all seem well, you may be nearly sure that the
vomiting is due to chloroform, and commonly you must
wait till it spontaneously subsides. I believe you cannot
cure it, and food put in the stomach only aggravates it.
The patient had better be without food, if in fair strength ;
but, if very feeble, he had better be maintained with
enemata of milk, eggs, beef-tea, and wine.
If vomiting go~on for six or more hours, or for days,
after the operation, and be not due to chloroform, it is a
very bad sign — I had nearly said a mortal one ; for
generally it tells that the operation has failed in its
desio^n. Either the strano^ulation is not relieved, or the
intestine is paralysed above the strangulation, or there is
peritonitis, or sloughing, or perforation of the intestine, or
some such trouble. Very rarely the untoward conditions
indicated by continuous vomiting are relieved spon-
taneously or with repeated doses of opium.
The persistence of abdominal distress, with tension
and pain and cohc, after the operation, is not so serious.
L 2
148 ON STRANGULATED HERNIA.
If Other symptoms be relieved, these probably will be ;
and they may generally be treated with large enemata or
aperients, such as the sulphate and carbonate of magnesia.
But there is no need of haste to give these things. The
abdominal troubles which they are to relieve are not due
to serious disease, but probably to intestinal accumula-
tion, which began before the strangulation, would be
very slow to destroy life, and may be allowed to remain
till it can be treated without risk. In such a case as this
— a not very rare case — when all seems well except the
abdominal pain and tension, be on the watch. If there
be no change, do nothing. With time, the intestines will
empty themselves. If there be increase of pain, without
increase of pulse or breathing or other evidences of fever
or inflammation, give enemata or aperients. I am sure
you may manage cases of this kind better and more
deliberately than I did some of those which I have re-
corded. I see now that I was over-busy with them, and
was only very fortunate in that I did no harm.
A large group of cases, much worse than these, may
be made of those in which the operation gives little or no
relief : all goes on after it as all did before, or everything
becomes worse. Few cases can be more grave than these.
You may think yourselves ha})py if, from twenty such
cases, you can save one.
The failure of relief from the operation may be due to
the utter exhaustion of the patient. I have had to
operate on ])atients already dying. I could not refuse to
operate, for I could not be certain that it would be use-
less ; but it proved useless, and seemed mischievous.
OPERATIONS NOT GIVING RELIEF. 149
The intestine was returned, and all put right ; but the
patient was too exhausted, as one may say, to be conscious
of relief, and went on dying, although carefully fed and
nursed.
Or the failure of relief may be because the strangula-
tion remains— a constricting band or misplacement of the
intestine, or some such thing, having been overlooked.
In such a case, especially if you have not opened the sac,
you must open the wound and the sac ; enlarge the
opening through the stricture ; find, if you can, strangu-
lated intestine or whatever may be wrong, and, if possible,
set it right. You may be so fortunate as to succeed —
more fortunate than I have been. But then, in two of
my cases, an internal and distant strangulation coincided
with that of the hernia. This was irremediable — could
not be reached ; and the second operation was as useless
as the first.
But by far the most frequent cases in which the
operation gives no relief, or only some slight and very
brief relief, from the signs of strangulation, are those in
which the intestine does not recover itself. It remains
nipped, powerless, congested or inflamed, spoiled, and in-
capable of contraction ; while the part of the canal above
it becomes distended, and after a time powerless, the
abdomen becoming constantly more tense, though it may
be with less turbulence of the intestines. This condition
is most frequent in the old, and after long strangulation ;
it is commonly attended with peritonitis ; and no doubt
the inflamed state of the muscular tissue of the intestine,
both in and above the strangulated part, is often the cause
of the loss of muscular power, or a serious hindrance to
ISO ON STRANGULATED HERNIA.
its recovery.^ But peritonitis is not a necessary part of
the calamity. I believe I have had cases in which no
peritonitis existed beyond the strangulated part. In such
cases as these, you may find the best hope, though the
best is seldom good, in opium, food, and wine, ail of
which you must give by the rectum if the stomach will
not retain them. Your object must be simply to keep
the patient alive while, in time, the intestinal canal being
at rest, may regain power. Very small quantities of food
may suffice for this — a few spoonfuls by the mouth every
hour or two ; and, twice or three times a day, injections
into the rectum of milk, beef-tea, egg. wine, and laudanum,
mixed all together.
Very similar to tliese cases are those in which
peritonitis, having begun before the operation, is not
relieved by it. There is, plainly, no reason why the
relief of strangulation should at once remedy the peri-
tonitis which the strangulation produced ; and it sometimes
seems to continue quite unaffected. Indeed, you had
better expect that this will be so, and follow what is a
very good general rule — that, namely, of giving opium
directly after the operation in all bad cases of strangu-
lated hernia, unless there be some clear reason for not
giving it. I have seen no harm come from this plan,
and I think it has sometimes done real good. What
are the bad cases I have already told you ? In any or
all of them, you may give a grain of opium, or an
equivalent subcutaneous injection of morphia, directly
after the oj)eration ; and then watch and determine
whether to give more, or what else to do.^ Especially,
1 Note XIV. » Note XV.
TROUBLES AFTER OPERATION. 151
you may expect to have to give wine very soon after the
operation, for the patients are generally feeble.
Thus, then, you may have in mind four sets of cases
in which the operation for strangulated hernia, though, to
all appearance, well done, does no good at all, or too
little to be counted. It may be so in patients utterly
exhausted ; in cases of persistent strangulation at the
hernia or elsewhere ; of intestine rendered powerless ;
of continuous peritonitis. Of all these I have seen ex-
amples. There may be others which I have not seen or
have overlooked. From all of these you may dis-
tinguish in thought, and generally in fact and practice,
those sets of cases in which untoward events arise after a
clear interval of relief from the operation. All may
go on well, or at least not badly, for a time ; the patient
may have a clear sense of relief; and the sickness and
other bad symptoms may cease for hours or some few
days ; and then come trouble and disappointment.
The cases that may be thus grouped are many and
various. I find among my notes instances of acute
inflammation of the hernial sac and its coverings ; simple
acute peritonitis, such as might be called traumatic ;
asthenic peritonitis, probably of erysipelatous nature ;
acute peritonitis, with rapid collapse, from intestinal per ■
foration or rupture ; simple inaction or paralysis of intes-
tine. And to those which were peculiar to operations
for hernia may be added other calamities, such as might
occur after any operation, as diffuse cellulitis, erysipelas,
phlebitis, and others.
It is not possible to speak of all these things now —
152 ON STRANGULATED HERNIA.
hardly even appropriate ; for, though those in the first
list are associated with hernia, they are not peculiar to it,
and their pathology and treatment must be studied on a
broader field. The peritonitis must be dealt with ac-
cording^ to the same rules as that which has nothino- to do
with hernia, using great care to determine which of the
forms I have enumerated is in each case present. The
strangulation may itself cause peritonitis ; and this, as I
have said, beginning before the operation, may continue
after it. The wounding and exposure of the peritoneum
may excite its inflammation, or greatly aggravate that
which existed before the operation. In both these sets
of cases, the signs of peritonitis will be observable directly
after the operation, or, at the furthest, within twelve
hours after it ; and these will generally be cases of acute,
or, so far as the constitution of the patient will allow, of
sthenic inflammation. But you may generally distinguish
from these the cases in which peritonitis sets-in after a
longer interval, and in which it is rather of an asthenic
type, whether it come from giving-way of the intestine,
or from such conditions as would produce erysipelas after
external ill] uries.
Do not suppose me to pretend that, in every case of
peritonitis after hernia, you can easily determine to which
of these different types of iiifiainmation it belongs. You
can determine often ; you should try to do so always ;
for according to the type of inflammation must be your
treatment. In tlie sthenic inflammations, you may give
great comfort and help to rec(jvcry by free local bleeding
witli leeches, by large poultices over the abdomen, by
weak saline and alkaline drinks, by the plainest and least
PERITONITIS AFTER OPERATION. 153
Stimulating diet. In the asthenic, opium is the only
remedy that is generally useful. It used to be calomel
and opium ; but I believe the calomel did harm oftener
than good. And with the opium must be rest and warmth,
and liquid nutriment and diluted wine. And I can state
no more general rules than these ; for the rest of the
treatment must be determined separately for each case.
Now, besides these very serious evils that may follow
operations for hernia, some local troubles may ensue, of
which a few are worth telling you of.
Perhaps the most common is acute inflammation of
the hernial sac, alone or with the immediately adjacent
part of the peritoneum. It is, I think, most hkely to
happen after operations for large hernia3 in old people,
when considerable force or time has been used in the
reduction. You may know it best by the localised pain
and tenderness with acute fever, without the signs of
unrelief or of general peritonitis of which I lately spoke.
There is no severe illness, but the general condition ap-
propriate to a sharp local traumatic inflammation ; and
you may treat it, in this view, with complete rest and
warm moist coverings of the part, and very little food ;
and, in the acute cases in robust people, with copious
leeching. In the acutest case wdiich I have seen, I applied
ninety-eight leeches in three days after the operation,
with great comfort, and I think great advantage, to the
patient. That was twenty years ago ; but it would still
be right to do the same.
Another local trouble is acute inflammation of the
cellular tissue outside the sac. It is chiefly seen after
operations for scrotal hernia and for deep-seated femoral
154 ON STRANGULATED HERNIA.
hernia. Commonly, the case appears going on well for
a few clays, and then comes a blaze of inflammation
in and beneath the skin, leading sometimes to abscess,
sometimes to diffuse suppuration. There is in these cases
nothing peculiar to hernia. The same troubles may, as
you know% follow any other operation ; and they always
need the same general means of treatment. I have never
seen serious evil ensue in any case of the kind
I might tell of other hindrances to recovery from the
operation for hernia ; but I limit myself to those of in-
flammation of the testicle, of sloughing of the scrotum,
and others which I have been able to study practically,
and I pass the others by, as I have done many other
things, especially the complications of herni^e with various
local diseases, such as hydrocele, varicocele, undescended
testicle, and others. I have seen only one or two cases
of each, and can tell nothing which is not already well
told about them. Indeed, for a conclusion, I must say
that, though to some of you it may have seemed excessive
to give four lectures on strangulated hernia, I have treated
the subject very superficially, very incompletely. One
lifetime is not nearl}^ enough for its complete personal
study, in even so large a field as this hospital supplies.
15:
CHRONIC PYEMIA.
Chronic Pyemia is seldom spoken of, and in many of
the best systems of medicine and of surgery is not so
much as referred to. Yet cases to which the name is
appropriate are not very rare. Such cases resemble the
well described and typical pyasmia in the formation of
w^idely dispersed shapeless collections of pus or other
allied inflammatory matter ; in the probability that these
formations are due to some infection of the blood by the
entrance of diseased inflammatory products ; and often
in the occurrence of rigors and profuse sweatings, of
phlebitis, and inflammations of joints. But they differ
from the acute type in that their course extends, con-
tinuously or with relapses, over many weeks or months,
or even over years, and is often free, at least in its later
stages, from all severe general disturbance of the health,
and from nearly all risk of life.
A record of some of these cases may promote a more
general knowledge and a better study of the disease ; a
study which is much to be desired for the avoidance of
the errors apt to arise, in this as in other cases, from a
too exclusive consideration of what we regard, perhaps
wrongly, as types of diseases.
The intimate relation of acute and chronic pyaemia
156 CHRONIC PYEMIA.
may occasionally be seen in cases which, after presenting
for a time all the characters of the acute form, assume a
very slowly fatal course. Of these I need not give any
detailed examples. It may be generally said of them
that, after presenting the ordinary signs of acute pyemia,
the disease continues week after week steadily destroy-
ing the health. Its course is indicated by slow wasting ;
all the tissues becoming dry and shrivelled ; by increasing
pallor ; by decreasing muscular and mental power, the
voice becoming weak, the mind slow and dull, and at
night often wandering ; by quickness and feebleness of
pulse and breathing ; by frequent and sometimes profuse
sweatings, especially when there is much suppuration ;
by less frequent chills or rigors ; by increased thirst and
usually aversion from food ; by dryness and shrinking
of granulations. I do not pretend tliat the general signs
of pya3mia can in every case of this kind be distinguished
from those of hectic or of mere exliaustion ; yet com-
monly they are distinct enough, and the distinction be-
comes very nearly certain when, as it often happens,
there appear occasional patches of redness on the skin,
or abscesses with flaccid walls, or oedema of a foot or
hand, or indiciitions of pneumonia.
It is not, however, of cases such as these that I wish
to speak. I refer to them only to make more evident
tlie relationship between acute pyasmia and those instances
which differ from it, not only in their slow progress, but
ill their comparatively mild general symptoms. To these
the name of chronic pyaemia is especially a})])r()[)riate.
CHRONIC PYEMIA. 157
I. Ligature of subclavian artery — Pya3mia on the ISth day —
Pycemial arthritis, lobular pneumonia, and pustular
eruption — Secondary hcemorrhages — Death on the 65th
day.
In June 1860 I tied the right subclavian artery of a man,
54 years old, who had a large axillary aneurism. He had fair
general health, but in textures appeared older than his age.
All went on well, except that his pulse, for some few days, had
gradually increased in frequency, till on the 18th morning after
the operation, he had a very severe rigor, followed by heat, and
then by profuse sweating. On the next (19th) day he felt
shaken, and rather feeble ; and he complained of pain like
rheumatism in his left shoulder ; but his pulse was slower, and
except for some recurrent sweatings, he had no general signs of
pyaemia or other severe illness. On the 20th day the ligature
was cast-off ; and on the 2 1 st he felt and appeared as well as
before the rigor, and might have been thought convalescent.
He had taken large doses of quinine and good food and wine.
On the 22nd day a profuse sweating occurred, and the pulse
rose ; and on the 24th a very severe pain ensued in the right
elbow, and, lasting for two hours, was followed by great exhaus-
tion and sweating, and increased rate of pulse and breathing.
On this day, also, there was an increased discharge of pus from
the wound, apparently from suppuration in or about the
aneurismal sac.
During the next ten days (to the 34th) the patient appeared
to lose flesh rather quickly. He often suffered severely with
pain in the left shoulder and right elbow ; nearly the whole
of the right upper arm became very large with oedema and
appearances of suppuration pointing at the elbow ; he slept
little, had profuse sweats, frequent chills, and no appetite ; his
pulse became weaker and was seldom under 100 ; his breathing-
less full, and generally 30 in the minute. Pus was freely dis-
charged, and welled-up through a small opening which alone
remained unhealed at the wound. Full quantities of stimulants
and all the food that could be taken seemed to produce no
/^.Ji
158 CHRONIC PYEMIA.
effect. Bat in the next week (35th to the 41st day) a marked
improvement in the general symptoms took place. The patient
every day called himself 'better,' or 'quite well;' he slept
well, and rarely sweated ; his pulse ranged from 96 to 108,
and was always soft and moderately full ; his breathing became
daily slower, his tongue was always clean, his appetite pretty
good ; his bowels regular ; and he sat up in bed for a short
time every day. The oedema of the arm and the suppuration
about the sac appeared stationary ; but there was neither pain
nor rigor.
On the 41st day, the pulse, without evident reason, rose to
1 20 or more ; and on the 42nd secondary haemorrhage, to the
amount of a pint, ensued through the opening at the wound.
In the next three weeks, to the 61st day, bleeding to a few
ounces occurred twice. The suppuration in the upper arm was
profuse, with discharge at the elbow, and after a time at the
axilla through an opening spontaneously formed. (After the
formation of this opening the operation wound healed in two
days.) The patient became constantly thinner and weaker ;
yet he often said that, but for his local ailments, he should feel
quite well ; and indeed he had no signs of general illness more
than any one would have with losses of blood and profuse sup-
puration. Yet twice, during these weeks, he had thinly
scattered pustular pyoemial eruption on the trunk and limbs,
and for some days near the end of the time had quick breath-
ing and cough connected, most probably, with pyasmial
pneumonia.
On the 63rd day severe hazmorrhage again occurred, and
tlien a sharp rigor, followed by heat and sweating. Again all
these were twice repeated on the 65th day, and then he died.
At the examination after death (in addition to the disease
connected with the aneurism, which it is unnecessary to
describe here), some purulent deposits were found in firm cir-
cumscribed spots in the upper lobe of the right lung; tlie left
shnidder-joint was full of pus, and the cartilage of the humerus
was thin, soft, and partially, detaclied : and in tlie right elbow-
joint all the articular cartilages were removed, and the ends of
CHRONIC PYEMIA. 159
the bones were rough with superficial ulceration. The lower
fourth of the right humerus was bare and surrounded with
pus.
II. Lithotoiny — Rigors on the folloiuing day — Repeated sup-
purations in the sterno-clavicular region — Rigors and
ejnleptiforon convulsions — Suppuration in theprostate —
Phlebitis — Recovery.
In July 1859. 1 performed lateral lithotomy on a gentleman
34 years old, a patient of Mr. Hewer. He was of naturally
robust health, but now worn-down by suffering and by resi-
dence in China. The stone was large and soft. The operation
had in it nothing worth describing ; but in the course of the
day after it the patient had three sharp rigors, after as many
times of passing urine through the urethra. During the next
day he began to complain of pain, like that of rheumatism,
about his left shoulder and clavicle. This continued and
increased, and was soon attended with increasing swelling, and,
at the end of the first week after the operation, issued in the
formation of a large deep abscess over the lower left cervical
and subclavian region, which abscess was opened. During the
same week the pulse was seldom under 120 ; and frequent
profuse sweatings occurred ; but with these exceptions there
was nothing materially different from an ordinary favourable
progress after lithotomy.
In the second week recovery continued, and at its end the
patient was able to leave his bed and walk to his sofa every
day ; his urine passed freely through the urethra ; and ' he had
not a bad symptom.' But he was annoyed with ' prickly heat,'
such as he often had in China, and with the continued sup-
puration about the clavicle, for which two more punctures were
necessary, and with which some sloughing of the subcutaneous
tissue was now connected.
Sixteen days after the operation, after a rather restless night,
but with no other warning, he had a rigor of the greatest
severity ; then a long hot stage, and then profuse sweating,
which lasted through the day. They were like those of very
i6o CHRONIC PYEMIA.
bad ague ; and he had had ague ten years before. Large doses
of quinine were ordered.
Soon after the rigor, a part of the swelling near the front
of the neck, which had been much raised and boggy, as if there
were sloughs under it, almost completely subsided ; yet there
was no increased external discharge of pus. During the night,
there was profuse sweating ; but on the next and following
days, to the 25th, the patient's condition returned to what it
had been before the rigor, except that he sweated more and had
a slower pulse. The only apparent consequence of the rigor
was the formation of an abscess over the upper piece of the
sternum and the adjacent costal cartilages, which was let out
on the 23rd day. With this exception, he appeared conva-
lescent.
But on the 25th morning, after much distress in the bladder
and rectum during great part of the night, the patient had an
epileptiform seizure which lasted an hour, and was followed by
great rapidity of pulse and profuse sweating. Before this ' fit '
the parts about the abscess over the sternum were observed
puffed-up and swollen ; after it, they had quite subsided, though
without any visible discharge of pus. In connection with this
' fit,' which, in all its relations, appeared to be the equivalent
of a rigor, a large abscess formed in the left lobe of the prostate.
But the general health of the patient suffered no other disturb-
ance than would have been produced by an ordinary abscess in
the same part; and when the pus was discharged, by puncture
through the healed lithotomy-wound, he was at once relieved
from all trouble, general as well as local.
Tliirty-six days after the operation, wlien the patient's health
was so far restored that he was daily walking or riding out, he
was suddenly seized witli severe cramp-like pain in the legs,
the first symptom, as it appeared, of phlebitis of the posterior
saphenous veins, whicli, in succession, became hard and tender
at and below their junction with the popliteal. He was for
many days troubled witli tlie lameness and oedema thus caused,
but when these were remedied, his recovery seemed complete,
except in that the prostate-abscess led to the formation of a small
WITH ACUTE NECROSIS, i6r
fistulous communication between the bladder and rectum, which
only slowly closed. He had good health afterwards so long as
I knew him.
In both of these cases, condensed from full reports, the
general characters of pyaemia are clearly marked : yet they
differed widely from the acute type in respect of both time and
intensity.
A ' typhoid ' state is commonly referred to as most charac-
teristic of the general condition of a patient with pyaemia.^
Certainly nothing ' typhoid ' was observable in either of these
patients. Both of them, for many days together, appeared and
felt as if they were convalescent, even while, as we may believe,
the mischief of pyaemia was at work in them.
It may be observed, too, that in both these cases the healing
of the operation-wounds was unaffected by the pyaemia. The
same fact may be commonly noticed in chronic pyaemia ; and
even the healing of one pyaemial abscess while another is form-
ing, and while the patient is being gradually exhausted is not
rare ; but in these cases the healing of the wound is rather by
contraction and drying than by the organisation of new tissue.
The cases of chronic pyasmia longest in duration that
I have yet seen, occurred in connection with acute
necrosis (so-called) — i.e. necrosis apparently due to acute
diffuse suppuration between a bone and its periosteum.
The frequency of death from acute pyaemia in this disease
is well known ; yet I think there are no cases of pyaemia
in which death is more often escaped. Neither are there
any among which better evidence may be found that the
presence of pus is not essential, as the starting-point, for
what we assume to be a pysemial infection of the blood.
* I should not myself so speak of it. Among even the worst cases of
P5'3emia under my own care, both in the hospital and in private, many, and
I think the majority, of the patients have either never been Hyphoid,'^ or
have been so for but a short time, and then have passed into the fatally ex-
hausting form of the disease described at p. 156.
M
A
162 CHRONIC PYEMIA
III. Acute necrosis of the left os cede is — Phlebitis — Abscesses
— Acute inflammation of the right knee-joint — Necrosis
of the left femur — Inflammation of the elboiv and hip-
joints — Symptoms extending over three years.
In September 1859, I saw a lad, 11 years old, of health}^
constitution, and living in good circumstances. He was a
patient of Mr. Sainsbury, to whom is due whatever credit may
be given to medicine for an escape from pyaemia. In July 1858,
he had had gastric or typhoid fever of great severit}^, attended
with tympanites and a very painful state of several joints. But
from this he had completely recovered. In May and June
1859, he had numerous boils; and on the 6th of July was
almost suddenly attacked with a severe pain in his left heel and
ancle. This was ascribed, with fair reason, to excessive exer-
cises at cricket, and in gymnastics during which he hung on a
rope by his heels for a long time.
On July 7th the pain was less ; but at night it became
worse, and he put his feet into cold water to relieve it. During
this night he became delirious ; and he continued so next day,
with swelling and apparently great pain in the ancles, especially
the left one.
On July 9th, Mr. Sainsbury found him with acute fever,
delirium, abdominal distension, and general ' typlioid '
symptoms. Next day the integuments below the left ancle-
Joint and heel began to slough ; and in some days following, the
slougiiing extended rapidly, opening the ancle-joint, or that of
tlie OS calcis and astragalus, or both, and leading to the necrosis
of a large portion of the os calcis. For many days he ap-
peared dying — typhoid and exhausted, with rapid wasting ;
but he gradually recovered. The large piece of the os calcis,
with the attachment of the tendo Achillis, remained widely
exposed; and a laige portion of integument separated.
During this, the acutest part of his illness, occupying nearly
two months, the patient liad inflammation of the lymphatics or
veins, or both, of tlie left limb ; swellings seeming to threaten
suppuration, but subsiding, on the arms ; and an abscess on the
I
WITH ACUTE NECROSIS, 163
front of the upper part of the right leg', which was opened and
healed.
In the third month the right knee-joint became acutely
inflamed, with severe pains, and quiverings and startings of the
limb, indicative of ulceration of the cartilages, and articular
surfaces of the bones. This ended with contraction and firm
ankylosis. In the months following, while the patient's gene-
ral health was so far improved that he seemed to suffer with
nothing but the feebleness of a very slow convalescence, there
were repeated inflammatory swellings about the hip-joints, and
on one side ; but none of them suppurated : they subsided,
some during the repeated application of tincture of iodine, some
while using cold compresses. Month after month thus passed,
and in the summer of 1860, the abscess by the right knee
formed again and re-opened, and necrosis of the left femur
occurred, with repeated openings of sinuses and separations of
sequestra.
In November of the same year, a very acute inflammatory
attack occurred at the right elbow-joint, threatening suppuration
of the joint, and leading to contraction and partial stiffness.
In February 1861, the greater part of the dead portion of
the OS calcis, the seat of the first necrosis, separated ; and
thenceforward healing went on, and was in the course of the
year completed. The greater part of this year passed without
any recurrence of active disease ; and the patient, crippled in
the left foot, right knee and thigh, and right elbow, recovered
better health and strength than he had had since his illness
began. But in November 1861, another acute attack of inflam-
mation of the right elbow-joint occurred. It began, as all of
the same kind did, without any apparent cause, suddenly, in
the night, with severe pain, which continued many days ; was
attended with great heat and swelling, and with redness and
oedema of the integuments, and was followed by almost complete
stiffness of the joint. In March 1862, there ensued an equally
acute inflammation of one hip-joint, just like an ordinary acute
' morbus coxae ; ' but this also, treated like that at the elbow,
with leeches and cold compresses, and rest, subsided, and left
K 2
1 64 CHRONIC PYEMIA
only partial stiffness. In the summer of 1862, the right leg
suffered for a month with erysipelas, and a large abscess formed
in the left thigh ; and in November of the same year, the right
elbow-joint was for the third time the seat of acute inflam-
mation. From this time onward health was gradually with-
out interruption completely recovered, and with complete action
of the joints with the exception of the left ancle and the right
knee.
Strangely unlike as this case may seem to the ordinary
cases of pyemia — running their fatal course in a week or
two, or, as it is said, ' occasionally ' prolonged to seven
or eight weeks — it is yet evident that the unlikeness is
almost only in respect of time. If the events of this case
had all occurred in three months, instead of three years,
it would have been an ordinary case of pyasmia ending
well. But difference of duration is never alone sufficient
to indicate a difference in nature, or to justify a difference
of substantive-name, among diseases. However prolonged,
this and the like cases are still pya3mia, chronic or relaps-
ing.
The absence of nearly all respect to time is, indeed,
one of the many characters in which pyaemia differs from
the most marked specific diseases ; and this corresponds
with the absence of specific shape in the pysemial J
deposits, abscesses, and necroses ; with the common
characters of pya^mial pus and other products of inflam-
mation ; with the absence of all indication of a single
constant infecting material ; and with the transmutability
(as it seems) of pyajmia, with erysipelas, cellular inflam-
mation, and pucr})eral fever.
It may be a question whether, in such a case as that
' WITH ACUTE NECROSIS. 165
last related, there was any abiding disease of the blood
or tissues in the intervals between the successive outward
evidences of pysemia. We can judge, in such a question,
only by the analogy of other relapsing diseases — e.g. of
secondary syphilis ; and from this we may believe that,
during the whole period of liability to outbreaks, there
is continuous, though not stationary, disease.
In some of the cases of chronic pyaemia connected
with acute necrosis, the secondary affections are limited
to the bones, or greatly predominate in them. A girl,
11 years old, who was under the care of Mr. Eoden, of
Droitwich, had acute necrosis of the lower part of the
right tibia, and, almost coincidently, of a piece of the
left clavicle. Some months afterwards, she had necrosis
of a small portion of the left humerus, with considerable
suppuration around it ; and several months later, a deep
abscess, but not attended with necrosis, above the right
knee. In another similar case, a young patient had,
during four years, a succession of attacks of necrosis of
different bones ; all acute, none bearing any resemblance
to strumous disease. •
This election of a single tissue, and the observance
of an uniform method of disease, in the secondary affec-
tions, are characteristic of chronic rather than of acute
pysemia. They are very marked in some of the cases
that follow parturition, in which women suffer for many
weeks with a succession of abscesses in the subcutaneous
connective tissue of the hmbs, and usually (after long
suffering) recover completely. Such cases are also some-
times seen in men.
i66 CHRONIC PYEMIA
Among the least severe cases of pyasmia that I have
seen, — contrasting with the acute cases as strongly in
respect of gravity as the last related do in respect of
time, — have been some of those associated with disease
of the urinary organs or with catheterism.
IV. Urethral stricture — Retention — Catheterism — Rigors —
Pyoiinial abscesses — Tumour-like formation about the
femur — Liquor potass ce — Recovery.
A sallow unhealthy-looking man, 40 years old, was admitted
into St. Bartholomew's on January 27th, 1863, with old
strictures, and recent retention of urine. The usual treatment
was pursued, with the warm hath and opium, and afterwards with
catheterism. He was completely relieved, and taught the use
of the catheter ; and was discharged, apparently in his usual
health, on February 10th. Just before he left the hospital, a
No. 8 catheter was passed easily.
On the night of February 11th, about thirty-six hours after
his discharge, without any reason that he could assign, he had
violent rigors and great pain, like that of rheumatism, in his
right shoulder. On the 12th he had some haemorrhage from
the.urethra, and about the same time noticed a painless swelling
on tlie right of the upper half of the sternum, and soon after
another swelling under the urethra, just in front of the scrotum.
With these, and complaining of dyspnoea and pain in the chest,
he was again admitted into the Hospital on P^ebruary 14. Soon
after his admission, a third swelling was found, seated over the
left olecranon. All these swellings were or became abscesses :
that over the sternum was open on the 14th ; that by tlie
urethra burst into the canal on the 18th, and tliat over the
olecranon was opened on the lOtli ; and (to end their history),
they all healed within tlie following month.
Two days after his admission, the patient's general condition
■was only such as miglit be found in any one with abscess from
ordinary causes. He had been rather more ill on admission,
WITH URETHRAL AFFECTIONS 167
but, as it seemed, only from distress added to the irritation of
the formipg abscesses. After two days' rest, he had a cool,
moist skin ; his tongue was but little furred on the middle ; his
pulse 108, full, and soft ; breathing 20 ; his bowels acted daily,
he passed healthy urine freely, and, except that he slept
little and was feeble, he could hardly have been thought ill.
Near the beginning of March, the patient observed a swel-
ling on the outer and front part of his left thigh. This gra-
dually increased, and at the middle of April covered at least
three fifths of the front and outer part of femur, to which it felt
as if immoveably fixed. The swelling was oval, smooth, not
perfectly defined, firm, and apparently solid, or as if a solid
infiltrated with fluid. The integuments and all the adjacent
structures appeared healthy, and very little pain was produced
by even rough handling. A small puncture let out a little
bloody serum. The general condition of the swelling appeared
to be that of a deep-seated inflammatory infiltration of all the
tissues round the bone — but some thought it a firm tumour
growing from the bone ; the more readily because the patient's
health seemed undisturbed. He went out daily, and was in
every respect convalescent.
By the middle of April, the swelling had gained its greatest
size, increasing the circumference of the limb by two inches.
The patient was now ordered to take a diachm of liquor potassse
three times a day, and to make no change whatever in his
manner of life, or any of the conditions in which he was placed.
Very shortly the swelling began to decrease, and with no other
evident change than that of diminishing size it gradually dis-
appeared, and by the end of May was gone. Soon after, the
patient left the hospital apparently well, and he showed himself
a month later in the same condition.
V. Lithotrity — Acute general disturbance — Abscess in the
fore-arm, and threatened abscess in the thigh,
A gentleman, 40 years old, invalid with the consequences of
an empyema of many years' duration, had a calculus of lithic
i68 CHRONIC PYEMIA.
acid, which was to be removed bylithotrity. The first crushing
was on January 4th, and was followed by no general disturb-
ance. The second, on January 10th, was followed on the next
day by a greatly increased rapidity of pulse, — it rose from near
90 to 140^ — by rapid breathing, redness and dryness of the
tongue, impaired appetite and digestion, frequent vomiting,
heat and wetness of the skin. These symptoms continued for
five days, with little variation, and then gradually subsided.
During and after their continuance, the urine contained more
than usual mucus ; but the irritability of the bladder was not
increased. A third crushing was done on January 16th, and a
fourth, the final one, on January 22nd.
While the patient was suffering with the severe constitu-
tional disturbance above described, he began to complain of
pain in the left fore-arm, and in the front and upper part of the
left thigh. In the former there slowly appeared a widely-
diffused oedematous swelling, tense and painful, which, with
gradual concentration about the middle of the ulnar aspect of
the fore-arm, ended in a large abscess in the deep subcutaneous
tissue. This was opened on January 27th, and, after freely
discharging thick pus, and several times apparently healing and
then re-opening, finally closed on March 23rd. The pain in the
thigh was succeeded by a swelling, similar to that in the fore-
arm, but much larger, extending from the great trochanter
over all the front of the hip-joint, and far inwards and down-
wards. At the end of January, it appeared to have already
suppurated ; but the calculus having been all evacuated, and
the patient seeming to be only extremely feeble, 1 advised him
to leave liondon for his home in fresh air. There, with return-
ing strength, the abscess in the fore-arm healed ; the swelling in
the thigh slowly disappeared without discharge, and the patient
regained and long retained his usual health.
Still less severe in its general symptoms than cither
of these two, was the following case : —
VI. A young man was imder my care in the Hospital
in March, and April 1862. He was admitted with spontaneous
CHRONIC PYEMIA. 169
moderately acute inflammation of the right inguinal glands.
A small puncture was made into the centre of the swelling ;
but it contained no pus. A few days later, acute oedematous
inflammation of the scrotum set-in ; while it was subsiding
without suppuration, the internal saphena and some other veins
of the left leg became nodular, hard and tender, with pains and
heat, as in ordinary adhesive phlebitis ; and, in a day or two, a
similar affection appeared in the veins of the right leg. When
these had nearly recovered, pains and swelling, much like
those of acute rheumatism, ensued in one hand and elbow, and,
after a few days, in the opposite wrist. After an interval of
rather more than a week, and when the patient seemed nearly
completely well, a swelling appeared b}^ the anterior spine of
the right ilium, not far from the glands that had been inflamed.
This suppurated, and discharged the only pus formed in the
case. While it was discharging, the right spermatic cord
became painful and hard. Then knotted hardness, pain, and
tenderness ensued, in succession, in some of the subcutaneous
veins of the left fore-arm, left upper-arm, and right fore-arm.
With these the case ended, and, after two months' illness,
the man regained his usual health and strength. During the
whole time he had no more or other general disturbance of his
health than is usual in each of the inflammatory diseases from
which, in unusual succession, he suffered. In the intervals
between them he was weak, but not ill.
If it should seem to some that cases so comparatively
trivial as these cannot properly be called by the same
name as those from which the ordinary description of
pyasmia is drawn, ^ I would observe that the difference
between the two groups of cases is only one of degree ;
and that a complete series of cases might be collected
ranging from the most to the least severe, and all re-
sembling one another more than any of them resemble
' See discussion on Mr. Hewett's paper. — ' Clin. Soc. Trans.' vol. vii., pp.
Ixviii., Ixxi.
170 CHRONIC PYEMIA.
the cases of any other disease. The differences between
the cases of acute and of chronic pyasmia are not greater
than those between cases of acute and chronic tuber-
culosis. Sameness of designation is, in both cases ahke,
justified by the rule that differences in degree do not
constitute or prove difference in kind.
The conclusions which the cases just related go to
prove may be thus summed-up : —
It is not rare to meet w^ith examples of disease pre-
senting the essential characters of pyaemia, but much
slower in progress, and much less severe and perilous,
than those from which pyasmia is usually described.
These cases are frequent enough to justify the general
use of the names ' chronic ' or ' relapsing ' pyagmia.
They are more rare among the instances of pyasmia
following wounds than among those occurring in diseases.
The local evidences of chronic are, more often than
those of acute, pyasmia, seated exclusively or chiefly in
different parts of the same tissues ; they are more
frequent in the trunk and limbs than in internal organs, ^
and when seated in the veins are most frequently found
towards tlie close of the disease. ^
^ Several instances in which pyccmia was chronic are related by Mr.
Prescott Tlewett in his address on pyaemia, published in the * Clin. Soc.
Trans.' vol. vii. 1874. In many of these the abscesses which formed were
confined to the limbs and the superficial parts of the trunk; and the lungs
and otlier internal organs escaped.
'^ Chronic pyajmia, indicated by a succession of large, flaccid, often pain-
less abscesses in the joints, or the subcutaneous or intermuscular tissue, or
beneath the periosteum of the long bones, accompanied by wasting, sallow
skin nnd wide variations of temperature, is occasionally seen in infancy and
childhood. It occurs as a sequela of scarlet fever, or some of the other ex-
anthemata. In some of the instances that have been observed no distinct
cause could be assigned. — [Kd.]
CHRONIC PYjEMIA. 171
The nearest affinities of chronic pyasmia are with
rheumatism, through gonorrhoea! or urethral rheumatism ;^
with simple or single abscess-formation after fever ; with
hectic fever ; yet, with very rare exceptions, the
diagnosis from all these is, in practice, clear.
The prognosis in chronic pysemia may, usually, be
very favourable ; especially when there are long intervals
between the successive local manifestations of disease,
and no evidence of serious pulmonary affection. The
slower the pulse and breathing, and the less the sweat-
ing, the greater are, in general, the probabilities of
recovery.
The usual treatment of chronic pygemia may be with
good food, patient nursing, a moderate use of stimulants
and tonics, and an abundance of fresh air. The value
of this last condition was strikingly shown in Case V.
The influence of the liquor potassse in Case IV. deserves
consideration. Its curative power seemed clearly proved ;
and I suspect that a part of its reputation for causing the
absorption of tumours is due to its influence on morbid
deposits imitating tumours, such as existed in that case.
^ Mr. Barwell in his work on ' Diseases of the Joints/ p. 101, maintains
a similar opinion. — [I'^d.]
\k*/^)
172
NERVOUS MIMICRY.
LECTUEE I.
A GROUP of cases of great practical importance is dis-
tinguished by this fact : that a nervous disorder produces
an imitation or mimicry of organic local disease. In
some of these cases the mimicry occurs without any sub-
stantial disease whatever ; in others it gives features of
extreme severity to a disease which, in a normal con-
dition of the nervous system, would be trivial or unfelt.
Much has been written on this subject — much that is
good ; but, if I may judge from the difficidties still often
found in discriminating between the real and the mimic
in diseases, there is need of writing more.
Cases of this kind are commonly included under the
name Hysteria ; but in many of them none of the dis-
tinctive signs of hysteria are ever observed, and from all
of them it is desirable that this name sliould be abohshed.
For it is absurdly derived, and, being often used as a
term of reproach, is worse than absurd. To call a
j)atient hysterical is taken by many people as meaning
that she is silly, or shannning, or could get well if she
pleased ; and no doubt there are patients of whom some
of these things may be fairly said ; but in many more,
NEUROMIMESIS. 173
hysteria, especially in the form of an unwilling imitation
of organic disease, is a serious affection, making life use-
less and unhappy and not rarely shortening it.
At any rate, let us, if we can, discard the name of
hysteria from surgery. If it is to be retained at all, it
may be for the cases of patients with hysterical convul-
sions and sense of suffocation, with the abdominal flatu-
lence, the nervous urinary secretion, and those other
associated signs of nervous disorder which are not imita-
tions of other diseases, and are not themselves imitated.
These are characteristic enough to deserve a distinct
name, and hysteria will serve, at least as w^ell as hypo-
chondriasis and melancholy do for what they signify.
But the characters of nervous mimicry are also distinct
enough to make a separate group with another name.
In English we may speak of nervous mimicry ; in un-
translated Greek, of neuromimesis. To patients and
their friends the maladies may be said to be due to ex-
treme nervous sensibility ; or, if they also prefer Greek,
we may call them hyperassthetic or hyperneurotic ; —
anything but hysterical.
The chief practical interest of these cases is in the
diagnosis between them and the organic diseases imitated
in them ; and as it is only in clinical study, and on
clinical grounds, that they can be grouped, so I shall
keep to a clinical view of them, and shall speak of their
pathology only as subservient to their diagnosis. I am
the more content to do this because, in Dr. Eussell
Beynolds's essay on Hysteria in his ' System of Medicine,'
and in Dr. Anstie's lectures on it in ' The Lancet,'
you may easily find the whole subject recently and
174 NERVOUS MIMICRY,
accurately taught. Indeed, if it were not that I liiay
treat the surgical part of the subject more fully than
they, I should not have seen room or occasion to lecture
on it at all.
Now, there is scarcely a local organic disease of in-
visible structures which may not be mimicked by nervous
disorder. You hear of hysteric cough and hysteric
aphonia, of hysteric dyspepsia and paralysis, of hysteric
joints and spines; and there is scarcely any of these
disorders in which the mimicry of real diseases is not,
sometimes, so close as to make the diagnosis very
difficult.
The means for diagnosis are to be sought — fl) in
what may be regarded as the predisposition — the general
condition of the nervous system on which, as on a pre-
disposing constitution, the nervous mimicry of disease is
founded ; (2) in the events by which, as by exciting
causes, the mimicry may be evoked or localised ; (3) in
the local symptoms of each case. And I shall speak of
these things in this order ; though it is the wrong order
for the actual study of a case. In every clinical study,
the examination of the present disease should precede
that of its probable causes ; though for lectures and
reading the reverse order is usually the better.
First, tlien, as to the general condition of the nervous
system which disposes to mimicry of local disease. In all
well-marked instances there is some prominence and ap-
parent excess of nervous action, leading to the general
expression of the patient's being nervous or of nervous
constitution. Neuromimesis cannot be found in all
persons alike, or in any person at all times. It may be
THE NERVOUS CONSTITUTION. 175
regarded as a localised manifestation of a certain consti-
tution ; localised, that is, in the same meaning as we
have when we speak of the local manifestation of gout or
of syphilis, or of any other morbid constitution which we
regard as something general or diffused, though distinct
witness of it may be in only one or more parts. And the
nervous constitution, hke others, is inherited in different
degrees of completeness or intensity ; and may, like
others, become less or more complete or intense accord-
ing to the conditions in which it has to live.
As to what is, verily, the peculiarity of the nervous
constitution, I believe we have nothing fit to be called
knowledge. It is even hard to give fit names to what
we may suppose it to be. We may speak of the nervous
centres as being too alert, or too highly charged with
nerve-force ; too swift in mutual influence ; or too deli-
cately adjusted, or defectively balanced. But expres-
sions such as these, or others that I see used, may be
misguiding. It is better for us to study the nervous con-
stitution in clinical facts ; and the life of almost any
patient with very marked nervous mimicry will supply
materials for the study. I have, indeed, seen a few in
whom I could find no other nervous error than the
present mimicry of some disease. But in the great
majority there is either history or present evidence of a
characteristic nervous constitution, such as may serve to-
wards diagnosis. Some have been, or are even now,
truly hysterical : subject to fits of irrepressible laughing,
crying, or sobbing, or to convulsions of various hysteric
kinds. But you will find nervous mimicry in very many
who have never been hysterical. In some the sensibility
176 NERVOUS MIMICRY.
is always too keen, whether for pain or pleasure. In
these the pain of an injury is much more severe than what
w^e may suppose to be the proper average of pain pro-
ducible by such an injury : it lasts longer ; outliving all the
other consequences of the injury. And, as to pleasure,
as a patient said to me, who suffered what she called tor-
tures from ordinary sources of moderate pain, ' the
pleasure of music is an agony.' But not all have this
compensation of feeling pleasure as keen as pain : for
many are habitually neuralgic ; they suffer with head-
aches, daitings in limbs, still more often with spine-aches
and the like, and are, as one may say, very painful
persons, — altogether hyperueurotic in their relations to
pain, but not to pleasure. In some of these patients,
again, the mutual influences of the mind and body are
too active. If they have ever fainted or vomited, for in-
stance, the recollection of the circumstances in which
they did so makes them faint or sick again. In some, all
impressions are too widely and vehemently reflected ;
the irritant that healthy people bear unobserved produces
convulsions, or some other seeming serious disturbance.
An intestinal worm, for instance, which some patients
would not feel, may in these produce the signs of all
manner of diseases. And some have already liad mimic-
ries of various other organic diseases, and will tell of all
the sensation-signs of these diseases, without having a
single mark of any organic change produced by them.
One of the most frequent conditions in those in whom
the neivous mimicries occur is a singular readiness to be
])ainfully fatigued by slight exertion. This is most
marked in tliose with spinal neuromimesis, but may be
SENSE OF FATIGUE. 177
found in many more ; and in some is the most marked
sign of the erroneous state of the nervous system. To
most of us the sense of fatigue produced by even exces-
sive exercise is scarcely distressing : only a great excess,
tending to exhaustion, would be felt as really painful ;
and the worst is soon relieved by rest. But these
nervous patients become utterly fatigued in even shght
exercise, and their limbs and their backs, though they
may look muscular and strong, ache horribly and very
long ; so that, not rarely, the attempt at more than usual
exercise is followed by great suffering, by sleepless
nights, and sometimes by nausea and vomiting. Their
sensations are like those of the painful fatigue which con-
valescents from acute disease feel after doing too much ;
but I believe there is never attendant fever such as con-
valescents in that case usually have : the likeness is only
in sensation.
Some or all of these, and of other forms of defect, or
error, or turbulence — call it what you will— of the
nervous system, you will nearly always find or hear-of in
})atients with nervous mimicries ; and in any study of a
case these conditions or their absence may add to the
grounds for diagnosis. But it is, I think, a fact of sin-
gular interest that, in even the most turbulent of these
nervous systems, the disturbance very rarely takes the
form in which morbid nervous influence produces, not
mimic, but real orf>;anic chanties. Of the thinofs imitated
hardly one is ever realised. I have not yet seen in any
hysterical or neuromimetic patient an instance of herpes
zona ; not even in those who have suffered long with that
infra-mammary pain which is not far unlike the neuralgia
ijZ NERVOUS MIMICRY.
commonly preceding the eruption. I liave not seen an
instance of rheumatoid stiffening of joints, Hke that which
sometimes ensues in disease of the spinal marrow, even in
the most tedious of neurotic joints ; nor one of the glossy
fingers, or the eczema, or the centripetal wastings, or, in
short, any of the organic diseases of peripheral parts whicli
are associated Avith injuries or oiganic diseases of nerves
or nervous centres. Neither are these patients particu-
larly liable to any forms of fever or of blood-poisoning ;
they incur as little risk from operations as any class of
healthy persons. The foct — I think it is one — is impor-
tant in both diagnosis and pathology ; and it is not
fiilsified, I believe, in any but a few ambiguous cases in
which what seems a mimicry of disease of the spinal
marrow passes into real disease, and leads to extreme
wasting of the lower limbs and arrest of the growth of
nails. The contrast is the more notable when we consider
that the distribution of blood is, in many of the mimic
cases, greatly affected. Heat and cold of the same part,
rapidly succeeding one another, flushing and pallor, tur-
gidity and collapse, — all these are frequent, striking, and
capricious in the nervous mimicries; but, after months and
years of their occurrence, not one organic change may be
discerned. You may find in our Hospital Eeports^ the
case of a gentleman who consulted me because, for
several years, whenever he walked far or fast, his feet
])ecame cold, white, and numb — ' dead,' as they are called ;
and tlicn, when lie rested, they fhished red and hot and
were turgid with blood, distending even the veins of the
> Vol. viii. p. G7.
MENTAL STATE, 179
leg. Yet, after j^ears of such disturbance, his feet were
as healthy as any of yours.
But now, to add again to the grounds of diagnosis : it
is seldom that patients with well-marked nervous mimicries
have ordinary minds — such minds as we may think
average, level, and evenly balanced. You may, indeed,
find among them some common-place people, with dull,
low-level minds ; but, in the majority, there is something
notable, good or bad, higher or lower, than the average —
something outstanding or sunken. This something is, in
different cases, so various that it is impossible to classify
or even to enumerate the diversities. But be clear that
these patients are not all silly, or fraudulent. Nothing
can be more mischievous than a belief that mimicry of
organic disease is to be found only or chiefly in the silly,
selfish girls among whom it is commonly supposed that
liysteria is rife or an almost natural state. It would be
safer for you to believe that you are likely to meet with it
among the very good, the very wise, and the most accom-
phshed among women. But it will be safest if you believe
only that, in any case of doubt whether a local disease be
organic or nervous, it adds something to the probability
of its being nervous if the patient has a very unusual
mental character, especially if it be unusual in the pre-
dominance of its emotional part ; so that under emotion,
or with distracted attention, many things can be done or
borne which, in the quieter mental state, are felt as if
impossible or intolerable. And this probability of mimic
rather than real disease will be much increased if the
patient's mind be set, in much more than the ordinary
degree, upon the real or supposed disease. In all the
N 2
i8o NERVOUS MIMICRY.
well marked cases of nervous mimicry, and in the less
marked in only a less degree, the malady determines the
general current of thought, and often of the whole life.
Egotism has its keenest life at and about the supposed
seat of disease. If the malady be not always uppermost
in the thoughts, it seems always in an under-current,
rising at every interval between the distractions of work
or play.
The contrast of the mental states of those who have
real and those who have imitated local diseases is often
very striking and of great help in diagnosis. Few patients
with real hip-disease or real spinal disease, for instance,
think half so much about their ailments as they do whose
nervous systems imitate those diseases. In this egotism
they resemble hypochondriacs : yet connnonly with a
areat mental difference, in that those with neuromimesis
are not distressed with constant forebodings of greater
mischief; they do not suspect that everything they feel is
a token of something much worse than can be felt ; rather,
they are content and often almost happy in their afflictions.
While the hypochondriacs are in a panic on account of
some trivial acliing, tlie ncuromimetics will talk of their
agonies with calm or smiling faces, or with lialf-closed
quivering eyelids ; sometimes, even, they seem well
pleased or proud in the immensity of their ailments.
This egotism in relation to the imitated diseases gives
to many patients an appearance of great wilfulness.
Some, indeed, are very strong-willed ; some are so for all
the good designs in which they engage, and some with a
thorougli, almost diagnostic self-service. But strong will
is, I think, less common among these patients than is a
STATE OF THE WILL. i8i
want of will. Sometimes there is a general feebleness of
will : the patients can do nothing for themselves ; can
trust themselves in nothing ; but commit themselves to
some one with a stronger will and an appearance, if not a
reality, of more knowledge. Hence, among these patients
are the most numerous subjects of mesmerism, spiritualism,
and the other supposed forces of which the chief evidence
is the power of a strong will over a weak one. But more
often you will find a feebleness or complete negation of
will in reference to the supposed seat of disease, while
towards other things the will is strong enough. You
may find the strangest inconsistencies in this respect. A
man who has intellect and will enough to manage a great
business, or to travel with much inconvenience and write
clever books, cannot will to endure sitting upright for
ten minutes, or cannot distract his attention enough to be
indifferent to an unmeaning ache in his back. A girl
who has will enough in other things to rule the house
has yet not will enough in regard to her limbs to walk a
step with them, though they are as muscular as ever in
her hfe. She says, as all such patients do, ' I cannot ' ;
it looks like ' I will not'; but it is ' I cannot will.'
I think it is to this same weakness of will that we may
attribute other things often observed in the worst cases of
neuromimesis, especially the disposition of the patients to
imitate or assume symptoms of disease that they have seen
or heard of, such as the deformities of diseased joints, the
lameness or paralysis associated with spine-disease,^ and
the supposed distinctive pains of cancer. No doubt there
is sometimes intentional fraud and Ij^iug in these cases ;
but in many more I think you may be sure that patients
1 82 NERVOUS MIMICRY.
do not study the imitation or deliberately determine to
practise it. Eatlier they are, in respect of will, like
children, who almost involuntarily imitate diseases ; for
instance in stammering, limping, and so on. I think that
many persons, even such as have good nervous systems,
must be conscious that it requires effort — that is, a full
exercise of will — to avoid these imitations, and to dis-
beheve or disregard sensations imitative of those endured
by others. And in the frauds which some of these
patients practise I am nearly sure that the fault is rather
in weakness of the will than in its perverse strength. As
other people cannot resist thieving or drinking, so these
cannot resist, have not will enough to resist, the induce-
ment to fraudulently exaggerate their symptoms, or even
to invent some. It is often very hard to distinguisli
between the frauds of the wilful and those of the will-less ;
but I have seen no reason to believe that wilful fraud in
disease is much more common among those with nervous
mimicry or hysteria than it is among others.
If you study nervous mimicry in all the varieties of
mental strangeness that may be associated witli it, it may
often seem to you an entirely mental disorder, due only
to imagination, or to intense attention directed on one
place, or to adoption of signs heard of, or, in many cases,
to an insanity of the intellect ; and it is not easy to find
sufficient evidence that it is not so. Imagination, fear,
and keen attention, association, and the tendency to
imitate distresses seen or heard of, might produce all tlie
morbid sensations of which patients tell, and might give
form and intensity to pains from any casual source of real
disease ; and as for the postures observed, for instance, in
MENTAL STATE. 183
mimicries of diseased joints or spines, tliese, it may be
said, are only such as are assumed instinctively for the
relief of pain ; and in an intensely sensitive person, with
no substantial reason for more than a slight pain, it is
probable that the subjective intensity of pain would
bring about the same postures of relief. Similarly,
flushings and transient heats might be all of mental
origin, as blushing is. If you study these mimicries from
the mental side, you may, I say, easily find reasons for
thinking them mere mental errors — insanities — rather
than erroneous workings of sensitive and motor nerve-
centres ; and you will be almost convinced of this view
of the case if you will read of the multiform and pro-
found inffiiences of the mind over the body in Dr. Tuke's
recent book ^ on this subject, or in any similar work.
But I think I may assure you, that to regard all mimic-
ries of organic diseases as essentially mental errors
would be bad pathology and worse practice. Let me
put the case before you very briefly, for I am lecturing
on diagnosis, not on pathology.
Some mimicries are essentially mental ; such, for in-
stance, as those in which patients, out of mere fear and
keen attention, acquire the pains of cancer, and localise
them in healthy parts ; and in nearly all mimicries a
mental influence may be discerned, just as it may in
nearlv all real diseases in which consciousness remains—
an influence often impossible to separate or weigh,
generally increasing with the duration of the disease, yet
not essential to it whether it be real or mimic. But in
some mimicries it is hard to discern any mental influence
* Tuke, ' Influence of the Mind upon tlie Body/ 1872.
1 84 NERVOUS MIMICRY.
at all. Some are imitations of diseases very far from
mental associations — in the cases, for example, of intestinal
distension, constipation of many days' duration, constant
vomiting and apepsia, ra})id heart- action with slow breath-
ing, largely pulsating arteries, and phantom- tumours.
Some are found in common-place, ignorant, and slow-
minded people wdio never saw or heard of the diseases
imitated in them. Some occur in children who could
neither imagine nor act what they tell and show, though
as they grow-up they may become those in whose suc-
cessive mimicries the mental influence takes a constantly
increasing part. And, to end, whatever may be ascribed
to mental influence, it can produce mimicry of organic
disease in only certain persons whose nervous organs
seem wholly prone to this manner of disorder, and whose
spinal and ganglionic systems must be deemed erroneous,
as well as, or more than, their brains. For nervous
mimiciy is not very frequent among the evidently insane,
and among the sane there are many who cannot bring-
about a mimicry of disease by any effort of imagination
or direction of the mind. Among these I am happy to
count myself. I have tried many times, carefully, and
with good opportunities, but liave always failed.
INHERITANCE. 185
LECTUEE II.
Ix the last lecture I spoke generally of the characters of
the nervous constitution commonly observed in those who
suffer with the mimicries of organic diseases. You may
believe that, however much the circumstances of a life
may favour the development of such a constitution, it
would not be well marked unless it were inherited. And
facts relating to inheritance deserve great weight in the
diagnosis of any doubtful case of nervous mimicry.
In looking for indications of this inheritance you may
not find that, in the same family, there are or have been
many cases of similar mimicry of disease ; but it is a fact
of not less weight if, in the same family, various other
forms of nervous disorders — especially of such as are, for
convenience, called functional disorders — have been
observed. Thus, among the relatives of those with
neuromimesis it is common to find cases of mental
insanity, extreme ' nervousness ' and eccentricity, stutter-
ing, convulsive and emotional hysteria, various neuralgise,
extremes of mental character whether good or bad, and
sometimes (but I think less frequently) epilepsy and
paraplegia. These evidences of family-relations may
help in diagnosis, just as, in the diagnosis of a doubtful
tuberculous disease, it is important if, among the members
of the patient's family, there have been many more than
an ordinary number of cases of pulmonary tuberculosis,
of tuberculous lymph-glands, of lupus, or of perforating
1 86 NERVOUS MIMICRY.
ulcers of the nasal septum or soft palate. So, in the
diagnosis of a doubtful case of gouty disease, it is im-
portant if relatives have had either typical gout, or many
of the less marked forms of gouty affections of the skin,
or kidneys, or any other part. It is a general fact, that
if any constitutional disease is prevalent among many
members of the same family, it affects them variously,
in different degrees of intensity, and in different parts
and textures ; but by this diversity the total value of the
evidence of inheritance, as bearing on a doubtful case, is
not diminished.
The family- relationship between the nervous mmiicries
and mental insanity is specially worth considering. It
helped us to the diagnosis, as some of you may remember,
in the cases of two girls who were at the same time in
Sitwell ward : one with strongly marked mimic disease
of the hip ; the other with very slightly marked real
disease. The mother of the former was in a lunatic
asylum ; the motlier of the latter died tuberculous.
I believe that a large majority of the w^orse cases of
nervous mimicry occur in members of families in which
mental insanity has been frequent. And the fact is
important, not only for diagnosis, but for pathology.
It may serve to strengthen the view that nervous
mimicry is a mental disorder ; but I beheve it may be
more rightly read as an indication that, whatever mental
insanity may be as a disorder of some portion of the
brain, the like is nervous mimicry as a disorder of other
nervous centres. Surely, any nervous centre may ' go
mad ' as well as any part of the brain which is appro-
priate to any part of the mind ; and may be mad in
RELATIONS TO AGE AND SEX. 187
different ways, imitating tlie idiotic, the emotional, the
maniacal, or other forms of insanity. But I only suggest
this for your study, and by the way. Let us see for
other grounds of diagnosis.
Nervous mimicry is much more frequent in females than
in males ; more frequent from the beginning of puberty to
middle age than in either earlier or later life ; more fre-
quent in the more cultivated than in the rougher classes
of society. But in what proportions it occurs in each of
these several groups it seems impossible to tell with any
fair approach to accuracy ; for no one has a field of
observation so general, or so equally inclusive of all these
groups of persons, as to be able to count fairly among
them. I should disbelieve any statistics pretending to
settle the proportions accurately. You may be sure that
neuromimesis is most frequent in young women of the
more cultivated classes ; but you may be equally sure
that it is not so rare among men, or children, or at any
age, or in any social condition, as to make it unreasonable
to suspect it in any case of obscure disease. You had
better not let any such case pass without asking yourself.
Is this disease, or any part of it, mimicry ? Some of the
worst cases of mimicry of disease of the spine and pelvis
that I have seen have been in men and women of mature
age ; some of the worst of joints in young children ;
some of the worst of all kinds in poor people.
It is equally or more difficult to find any general
characters of health, except those of the nervous system,
which may help to the diagnosis of mimicry from real
disease. Some of the patients are in various degrees
gouty ; some are tuberculous ; some scrofulous. The
1 88 NERVOUS MIMICRY
nervous constitution may be mingled in various propor-
tions with any others, adding its own characters to theirs,
making pain more intense, spasm more severe and
frequent, or receiving from other constitutions characters
of oro'anic disease very difficult to eliminate.
These various combinations of constitutions must be
well studied. The most troublesome is the combination
of the nervous with the gouty constitution. For in one
in whom gout is not complete there are never wanting
strange sensations — of tinglings, burnings, pains, pressures.
In the neuromimete these become intense ; his nervous
system defines them or gives them form ; and the difficulty
of diagnosis becomes extreme. And as the combination
witli gout is the most troublesome, so that with tubercu-
losis is the most dangerous. It is through this that many
die wdiose maladies have been made light of, and called,
with a sneer, hysterical, or only nervous, or the like.
They die, and often die young, not through their nervous
malady, or anything directly affected by it, but through
tuberculosis or some allied disease which they have
inherited, and whicli their invalid habits have made it
impossible to avert. Of the nervous constitution itself
very few if any die ; some remain miserable invahds all
through life, till some casual disease, aggravated by
tlieir general feel)leness, removes them : but the majority
get well ; they live through the time of life in which the
constitution is most marked, and then their nervous
systems become more tranquil, balanced, and orderly.
I think there is no constitution in which nervous
mimicry is so commonly found as in patients who are
said, and perhaps truly, to have a very bad circulation.
IN THE COLD-BLOODED. 189
Chiefly, these are marked by being habitually cold-foot eel.
In nearly all weathers and all times their feet feel no
warmer than the air ; indeed, they feel colder, and are
often damp and, in those who are not ana3mic, are purple
about the sides of the toes and under the nails. Some-
times the hands are habitually in the same condition, and
the skin on the back of the upper arm is usually dusky,
pink and purple, coarse and papillary.
Doubtless this coldness tells of very slow movement
of blood in the skin of the cold parts ; and, in seeming
agreement with this, the heart is commonl}^ feeble,
irritable, and swiftly acting, so that the pulse is very
quick, while the breathing is comparatively slow. Often,
the inconsistency of a quick pulse with only natural or
slow breathing and a low temperature may nearly suffice
to tell that some very painful disease of long standing is
only ' nervous.'
But, besides, this habitual or very frequent coldness
of the feet probably indicates a contraction of the small
blood-vessels dependent on disorder of nervous supply.
For the phenomena are very variable. Some patients
have such feet as, they say, cannot be Avarmed : they are
cold all night, cold wdiile long wrapped in warm flannel ;
and even when warmer they may become cold under
mental influence. But in some the feet, after being cold
all day, flush in the evening ; in others they become red
and even painfully hot, puzzling the student of diagnosis.
Such variations in the state of bloodvessels in any
part seem to tell of nervous disorder overrunning from
the cerebro- spinal into the vaso-motor nervous system.
They are weighty evidences in favour of nervous mimicry
190 NERVOUS MIMICRY.
in any doubtful case ; and they become more so when,
however often and extremely widely the supply of blood
may have varied, the nutrition of the part remains un-
affected.
The temperature of a patient in whom you are
doubting between real and mimic disease should always
be observed. Speaking generally, it is not affected in
any degree proportionate to the signs which may seem
like those of acute disease. With a joint or a spine as
painful as in the most acute inflammation, there is usually
a constantly natural temperature ; and so of other
nervous disorders imitating inflammations in other parts.
And this inconsistency may settle your doubts. But if
the temperature be variable, or often high, you must be
cautious. You may rely much on heats and chills, on
shiverings and sweatings, as signs of true disease in parts,
and as very probably signs of suppuration ; yet they are
not quite sure. Many sensitive persons shiver on very
slight provocation ; for instance, wlien they are in pain
or anxious, or what they call bilious, or exhausted. In
liysterical persons, a shivering may take the place of an
ordinary hysteric fit. Weakly persons, by whatever
weakened, sometimes perspire very freely at night ; and
mere nervous excitement may raise the temperature to at
least 101°. I have seen a case in wliicli, for nearly a
month during convalescence after fever, the temperature
rose two or three degrees every night; the patient
had some signs of joint-disease, but tlie end of tlie case
showed that there was no real morbid process present.
And it may often be observed that, thougli witli little
or no organic disease, a nervous i)atient's temperature
TEMPERA TURE. 1 9 1
may be normal, or not above 101°, yet with a moderate
addition of acute disease the temperature may rise much
higher than it would in anyone with a healthy nervous
system. I perforated an abscess in a very hysterical
young lady's tibia ; a few days afterwards the escape of
pus was casually hindered, and in that evening her tem-
perature rose to 105°. In the next evening it was
104*1°. In the following morning it was 1005°; in the
evening 101*5° ; and then it fell nearly to normal. And
this had happened w^ithout any material pain or inflam-
mation ; and, even when the temperature Avas 105°, she
was cheerful, and with a pulse about 100. Her respira-
tion was natural.
These facts may be enough for caution against over-
reliance on any one sign of disease in patients of nervous
constitution, even though it be the measurable tempera-
ture. Prudently estimated, it is of the highest value,
even in nervous patients ; over-estimated, it is more
fallacious in them than in any others.
In all nervous constitutions, especially in those with
the habitual coldness of the hands and feet of which I
w^as just speaking, it is common for many of the internal
functions to be torpidly and scantily performed. The
bowels are often inactive, sometimes marvellously slow,
the gastric digestion is feeble, and menstruation is scanty
and irregular, or altogether suspended ; but in these
things there is no rule : in some nervous mimics the
functions of organic life are done well enough.
In the defective ovarian and uterine functions of
certain patients some see the centre and chief substance
of the whole disease : a very mischievous fallacy. Of
192 NERVOUS MIMICRY.
course the sexual organs appear generally in fault to
those who are rarely consulted for the diseases of any
other part ; but in general practice they are, in a large
majority of cases, as healthy as any otlier parts are, or not
more disturbed. The close and multiform relations of
the sexual organs with the mind, and with all parts of
the nervous system, are enougli to make the disorders of
these organs dominant in a disorderly nervous constitu-
tion ; but then- relation to ' hysteria ' or to ' neuro-
mimesis,' though more intense, is only the same in
kind as that of an injured joint or an irritable stomach.
All, in their degrees, may be disturbers of a too perturb-
able nervous system ; and equally on any one of them
the turbulence of a nervous centre may be directed with
undivided force.
In patients with very strongly marked nervous con-
stitution, a mimicry of organic disease may ensue as if
spontaneously — without provocation. And the chances
of such an event are greatly increased in the weakness of
convalescence after acute disease, a condition in wliich
whatever is wrong in any constitution lias the best oppor-
tunity of ap{)earing in force. But much more generally
the mimicry begins after some event which has the rela-
tion of an exciting cause, determining in many instances
not only the occurrence of the mimicry but its locality.
These exciting causes may, then, be our next subject;
and these also may be studied chiefly with a view to diag-
nosis.
Among the chief are sudden mental distresses, emo-
tion, disappointment, long anxieties, or exhaustion by
MENTAL CONDITIONS. 193
overwork. When any of these can fairly be traced as
inducing a seeming organic disease, the probability of a
neuromimesis is increased. Sometimes the effect of
mental strain is very striking. I saw one day a young
gentleman who had been overworking for a civil service-
examination. After a three hours' mathematical cram
he fainted, and when he rallied had a very close mimicry
of paraplegia, which lasted many weeks. On the same
day I saw a gentleman who had been greatly overworked
in a prosperous business. He kicked his great toe severely,
and had a mimicry of tetanic convulsions in the limb,
with night-panics and other curious nervous symptoms,
which after a few days were followed by the sensations of
spinal disease such as one of his brothers died with.
This patient was supposed to be strong, but was really
very nervous, timid, and watchful. The other was
generally calm, active, and vigorous ; but one of his
sisters had had severe hysteria and apepsia.
In cases such as these the mental disturbance appears
as an exciting cause ; in others of longer duration, as
with constant anxious watching or any feelings long
suppressed, if the mental states may not be regarded as
exciting causes, they so greatly enhance the tendency
to nervous mimicry that its outbreak may seem spon-
taneous.
In another form, a mental condition may be regarded
as the determining or exciting cause — namely, when a
patient imitates unwittingly and unconsciously another
person's disease. In a case which I do not doubt was a
neuromimesis of hip-joint-disease, with limping, and with
eversion and contraction and some pain of the thigh, I
0
194 NERVOUS MIMICRY.
found that the patient's brother had advanced true hip-
disease — a fact which rather added to the difficulty of
diagnosis, for with the probabihty of similarity of con-
stitution in two brothers it might be deemed very pro-
bable that both would have the same organic disease.
Similarly, through sympathy, even without family re-
lationship, one person may acquire the sensations of
disease described by another. In the fortnight following
the death of the late Emperor Napoleon, I w^as consulted
by four persons who described, as they felt, the sensations
of stone in the bladder. One had some sUght disease in
the bladder ; the others were healthy men, except in that
they had nervous irritable bladders ; but there was not
any ground for a suspicion of stone in any of them, and
none of them had suspected it, or felt the sensations that
led them to the suspicion of it, till they were excited to
attention and suggestion of these sensations by the con-
stant thinking and hearing of what were supposed to be
the sensations of the Emperor.
More frequent probably than any mental state, among
the exciting causes of nervous mimicry, is injury of any
kind, especially of bones and joints. In the majority of
the cases of mimicry in these parts, and in the spine,
injury is told of as the cause of disease. The liistory thus
adds to the difficulty of diagnosis ; for injury is as often
the cause of real disease — and after injury, let me tell
you, nervous mimicry is not only more difficult to be sure
of, but harder to cure. For tliere is something tangible
to appeal to, sometliing which would indeed be quite in-
adequate to explain any severe symptoms in a person of
sound nervous system, but which the mind and mimicry
CONSTITUTIONAL STATE. 195
can invest with symptoms enough for even the gravest
disease.
In many cases you will find it very hard to tell what
has determined the locality of a mimic disease. If it be
not injury, it may be some inherited local disposition to
disease, or a special local excitability ; but when we can-
not even guess, there may yet be no ground for doubting
that the malady is mimetic, for we are in only the same
difficulty as we often are in trying to say why, e.g., gout
is in some persons localised in the hand, in some in the
foot, in some in the skin, or stomach, or bladder. In all
alike the constitutional malady may be clear, however
obscure may be the conditions determining its local
evidence.
I say the constitutional malady ; and let me again and
again repeat, that in every case of this kind you are to
look, for the essence of the disease, to the general condition
of the nervous system. There is no greater fallacy than
to suppose that nervous mimicry, or hysteria, or any of
the allied forms of disease, can be referred to any malady
of any other part than the nervous system. There is not
an injury or a disease of the ovaries, or prostate, or any
other part, to which hysteria, hypochondriasis, or any
allied malady has been referred, which may not be found,
in some persons, free from all nervous complications
whatever. It is only the hysterical by natural constitu-
tion who can be made to display hysteria by any local
disease or injury — only those who are by constitution pre-
disposed to nervous mimicry in whom such mimicry can
appear.
0 2
196 NERVOUS MIMICRY.
LECTUEE III.
ox NERVOUS MIMICRY (XEUROMIMESIS) OF DISEASES OF
JOINTS.
I HAVE said all that I think necessary, for help in
diagnosis, on the general conditions of patients in whom
mimicry of disease occurs, and on the events whicli
appear as exciting causes of the mimicry. I will now
speak of some of the special mimicries, beginning with
those of diseases of the joints, and still trying to teach,
almost exclusively, their diagnosis.
Let me repeat the rule that, in every case, you should
study the local before the general symptoms. You will
often go wrong if you take the contrary course. In the
most evidently hysterical patient there may be a real
joint-disease ; in the least evidently there may be a
mimicry : and the error of treating a real disease as
' only nervous ' is one of the worst that can be made ; it
may be as bad as that of amputating a limb for a mere
mimicry of disease.
Among the diseases of joints, those which are most
often imitated are the more or less acute inflammations ;
not, unless very rarely, the rheumatic or gouty or any of
that class, but the so-called common inflammations and
the scrofulous. If you would think of the importance of
studying them, remember that Sir Benjamin Brodie, to
whom more than to any one else of any time we are in-
OF DISEASE OF JOINTS. 197
debted for knowledge in these subjects, said that, ' among
the higher classes of society, at least four-fifths of the
female patients who are commonly supposed to labour
under diseases of the joints labour under hysteria, and
nothing else.' This statement, of course, does not refer
to the class of gouty and rheumatic diseases of the joints ;
and it needs, I believe, an amendment by the omission of
the words ' and nothing else,' for part of the large pro-
portion is made up by numerous cases of trivial disease
or injury made to seem severe by hysteria or other
nervous fault. The words ' higher classes,' also, need
strong emphasis : for among my hospital-patients,
whether in or out-patients, I think I can be sure that the
proportion of nervous joints was less than one-fifth ; and
even in private practice the proportion of four-fifths is
not attained unless in practice almost exclusively among
the most cultivated classes.
Among all the joints, the hip and the knee, which
are the most frequent seats of real disease, are equally so
of the mimicry : a fact not easy to account for. It may
be due to mental association, perhaps unconsciously ; or
to a mingled inheritance — for instance, to an inheritance
of nervous constitution and of relative weakness in the
joint or joints most weak in progenitors. After the hip
and knee follow, in order of frequency, the tarsal joints
and carpal, or the elbow and shoulder ; but in these,
mimicries are too rare for counting.
Another fact, adding to the difficulty of diagnosis, is
that the most frequent exciting causes are the same for
the real and for the imitated affections of the joints.
Injury, or some great fatigue, is commonly referred to as
198 NERVOUS MIMICRY.
the source of the miscliief. The injury may seem in-
adequate for such trouble as followed ; but you cannot
rely on this. Many of the worst instances of scrofulous
arthritis follow injuries that seemed very trivial. It may
suggest a suspicion of neuromimesis if pain set-in with
full severity directly after an injury that was not severe ;
but the suspicion must be lightly held. One of the most
acute inflammations of the hip-joint I have seen set in
severely, with an almost agonising pain, directly after a
wrench of the joint in quickly turning round.
Thus, then, you can get little help for diagnosis
from either the seat or the apparent cause of the malady :
they are for the most part the same for the real and for
the mimic affection. Your reliance must be on the
examination of all the features of each case, and on a
riizht estimate of the wei<2^ht to be attached to each. Let
me then take, in turn, each of the signs of inflammatory
affections of joints, and see how far they maybe imitated,
whether separately or together. For although it may be
said, generally, that an inflammation of a joint should be
marked by many signs, and that in a well-mai'ked case
you may study them all, yet, in practice, you cannot
treat lightly any case which has even one clear sign of
diseased joint ; for this may be only the first sign, wliicli
others will follow, or the last, which has survived the
rest ; or it may be one which is so exaggerated as to
conceal the others. What is wanted in every case of
suspected disease is, that you should be able to say posi-
tively Yes or No ; and this you cannot do without know-
intx the weight in evidence of each usual sign.
First, as to pain. Alone, it is not to be at all relied
PAIN IN A JOINT. 199
on for a sign of inflammation of a joint ; especially if it
be severe. If a patient be ready to scream when tlic
accused joint is touched, and yet the joint is not over-
warm and the patient not feverish, you may be nearly
sure of neuromimesis ; and more nearly still if the pain
be rather in the parts outside or about the joint than in
the joint itself, so that a gentle touch is said to hurt as
much as a hard one, or a pinching of the skin as much as
pressure on the joint itself You must not even rely on
what are supposed to be characteristic pains, such as
those felt at the knee for disease of the hip, or about the
middle of the arm for disease of the shoulder, or even
those grinding and burning pains at night which some
regard as characteristic of ulceration of cartilages : all
these may be mimicked.
I had a boy aged about fifteen in the hospital who
had these night-pains in a most marked degree in one
knee, and the joint was a little swollen ; and he, being
tuberculous, was wasting, hectic, and very ill. I did not
doubt that he had destructive articular disease, and the
use of the actual cautery cured his night-pain — another
reason, some would have said, for being sure that his ar-
ticular cartilages were ulcerating. Soon after this he had
similar pains in or near the tibio-fibular joint, and these
also were cured with the cautery. But he went-on and
died with pulmonary tuberculosis, and I examined his
knee-joint and found it almost healthy. A very small
piece of one edge of the cartilage on the femur appeared
eroded, but it was a trivial change, and quite inadequate
to account for the severe pain of which the lad had long
complained.
20O NERVOUS MIMICRY.
The case had been one of nerve-pain at the joint, and
the imitation of organic disease had been made closer by
the sic^ns of the coincident disease of the Inncrs. But for
this, it might have iUustrated what you may take as a
general rule — that acute pain in a joint, if it has existed
for even a few days without either local or general in-
crease of temperature, is not a sign of acute inflammation
of the joint. It may be rheumatic disease or rheumatic
gout, or some slight inflammation after injury, in a
neuralgic person, but it is not acute inflammation.
There is more difliculty in judging of the meaning of
pain in a joint when it is not severe, but dull, aching,
' wearing,' as patients describe it. You must be cautious
in these cases. Pain alone is not enough to prove
organic disease ; yet the lower degrees of pain seldom
exist constantly and long without some organic mischief
I have indeed known several such cases, especially of
pain at the hip, the conclusions of which made me believe
that the pain was only nervous ; for the patients got at
last suddenly or very quickly well, without stiffness or
other apparent change at the joint, or with a sliifting of
pain to some other part. But in all such cases you must
be cautious and watch for other signs of disease addmg
themselves to the pain, such as local heat, swelling at the
joint, wasting of parts about it, and others that are least
dependent on the sensitive nervous system.
The pain I have been speaking of is that which may
be felt in the joint even while it is at rest. Different
from this is the pain wliich prevents the free movement
of the joint. It is observed alike in tlie real and the
mimic disease ; and you may often judge the pain to be
PAIN IN A JOINT. 201
mimicry by its inconsistent severity. If with scarcely
any other sign of disease a joint will not permit the
slightest movement because of pain, you may greatly
suspect the reality of disease ; but be very careful not to
overlook the signs of increased pain on movement in
cases of slight real disease, especially in the diseases of the
hip in children. You may often find this the only sign
making it clear that a child has real hip-disease. A sus-
pected joint may allow free and smooth and painless
movement till, for instance, in extreme abduction of the
thighs one adductor becomes much tenser than the other,
or in extension the loin is quickly raised, or, by some
other movement, it becomes evident that the joint will
not allow extreme movement without pain, although
within all but its extreme range its movements may be
free and painless.
In these, among many cases, chloroform or ether may
help in diagnosis. In the real disease, as in the mimic,
wdiile the patient is utterly insensible, the joint may be
moved as widely as in health, unless, indeed, there be
such changes in its structure as might alone have proved
its disease ; but commonly you will observe that, in the
real disease, the muscles become alert, and restrain the
movement of the joint before the patient has regained
consciousness ; while in the mimic disease there is no
restraint till consciousness is completely regained. The
test is a delicate one, but I think I may be sure that it is
a true one, and fit to be relied on, whenever the chief
sign of disease of a joint is a restraint of movement on
account of pain and the guarding action of muscles.
Closely allied with this pain on movement of an in-
202 NERVOUS MIMICRY.
flamed joint is its stiffness, with contraction or other set
posture, dependent on muscular action ; for this posture,
whether it be due to choice or to reflex movement, is the
posture of greatest ease, or of safest guard against weight
or shock or other causes of pain. The absence, therefore,
of the fixed or nearly fixed posture usually observed in
a diseased joint may always suggest the suspicion of mi-
micry. It would be rather strange to see a hip or knee
extended after many weeks of such pain as would be felt
in an acute arthritis, unless, indeed, they were rheumatic
or gouty, with exaggerated pain, or had been carefully
maintained in good position. It would require the pre-
sence of many other signs of real disease to counterbalance
the absence of this sign ; for diseased joints, left to them-
selves, will be habitually or always in the position easiest
to the patient.
But the reverse of this is not true. Very commonly
a joint mimicking disease assumes the posture of disease —
assumes and maintains it stiffly in even an extreme degree.
This may be seen even when there is no objective pain in
the joint; but much more, when the joint is a little really
painful. After a blow or strain the nervous condition of
a patient may either make the pain so intense as to de-
mand tlie position of greatest ease, or may bring-about
this position for the relief of even a little pain. Especially
the posture of hip-disease is apt to be imitated by the
drawing-up of one side of the pelvis and rotating it, so
that the limb looks shortened.
The conjunction of pain and stiffness in a joint always
looks like real disease ; but you may generally detect tlie
mimicry by observing tliat, while these things would in-
PAIN AND STIFFNESS OF JOINTS. 203
clicate disease of much severity, everything else is as if
there were no disease, or at most only a very mild
arthritis. The inconsistency of the several parts of the
case exposes its true nature. Lately I had to see a young
lady, with a reported healthy nervous system, wdiom I
found lying in bed with extreme contraction of the thigh
towards the pelvis, pain at the hip and knee, increased
pain on any touching near the hip-joint, and especially
great pain and tenderness at and about the tuberosity of
the ischium. She could not bear the least attempt to
straighten the joint, and the contraction was said to be
persistent during sleep. She had had vomiting, hated
food, and looked ill and distressed ; and all these troubles
were ascribed to slight injury or over-fatigue a few days
previously. The case looked very like real disease of
the hip ; but if it had been so at all it must have been a
very acute disease, swift and severe, such as should have
had attendant fever. Yet the pulse and temperature
were natural, and there was certainly nothing in the case
which m.ight not be explained by mere nerve-disturbance.
And the event proved that there was no organic disease,
for after a few days' rest, with careful food, and some
wine, and mental quietude, the pain ceased, and then very
slowly the limb resumed its natural power and posture,
and the young lady married and is well.
Let me here tell you of two or three notable groups
of cases of pain and stiffness of joints without real disease.
None are more frequent than those of boys from 10 to
15, who complain of pain and declare themselves unable
to walk after injuries of the ancle or knee, or who disuse
their arms for pain after injuries of the elbow or other
204 NERVOUS MIMICRY.
part. They describe the pain as horrible, and hold their
limbs in some unnatural position, and limp and cry when
you try to make them walk ; yet you can find nothing
wrong in the shape, or size, or temperatiu'e of the joint,
or in the general health. It is very hard to say whether
they are shamming or neuralgic ; but the utter inconsis-
tency of their cases proves that they are the one or the
other, and you must make them use their limbs. They
will often do it better if you have first moved the joint
sev^erely for them, and ' loosened ' it.
Something like these, yet different in having little or
no pain, are the children who mhnic a disease of a joint
through fear. After a hurt the immense care bestowed
on a joint, and the earnest injunctions not to move it,
seem to impress some children's minds so deeply that,
long after all is well, they hold up their joints scrupulously
and timidly, and dare not try to use them. You may
amuse yourselves with the astonishment with which both
child and parents find, on a positive assurance, that
walking or any other use of the lame limb is quite easy
and painless.
Another group allied with these is that in which you
find young people with joints contracted by involuntary
and quiet muscular power after injury. The joints are
painless unless when great force is used at thera ; and you
can easily feel tliat their stiffness is not through inflamma-
tion or adhesion, but through muscular resistance like
that which sometimes produces wry-neck directly or very
soon after a IjIow. You feel a kind of elastic recoil at
efforts to move them, as if the effort were resisted by a
tough elastic substance. Ether or chloroform decides at
DEFORMITY AND DISTORTION OF JOINTS. 205
once the diagnosis : as soon as the patient is insensible
the joint becomes moveable as widely and as smoothly as
an uninjured healthy one, and only slowly if ever stiffens
again.
Just like these are the ordinary cases of painless stiff
joints in hysterical girls : the muscles hold them fixed,
and that is all ; the joints are healthy to the touch and
the sight, and even to the patients are painless unless vio
lently used.
In all these cases the ground of diagnosis is essentially
the same. You have one or two or three signs of the dis-
ease of a joint present in an extremely marked degree, or
at least well marked ; a pain, or a stiffness, or both, and
limping or other consequent disability, such as would
exist in a joint severely or long diseased. But with a
joint really thus diseased there should be — unless it had
some chronic-rheumatic, or gouty trouble — swelling, or
heat, or spoiled shape, or general wasting of the limb, or
all these together ; and with them usually some disturb-
ance of the general health. The absence of these is
weightier evidence than the presence of the other
symptoms.
All that I have just been saying relates to the distor-
tion of joints produced by muscular action, not to de-
formity due to displacement of one or more of the bones
forming the joint, such deformity as you see, for instance,
in the knee, when the tibia falls backwards and outwards
from the femur, or is rotated by the weight of the foot,
on which also the bedclothes may have been allowed to
rest. When this or any similar deformity exists, it is a
nearly sure sign of real disease, past or present, for it can
2o6 NERVOUS MIMICRY.
scarcely happen except tlirougli textural changes, through
softeninor of the hi2:aments and other structures about the
joints permitting one bone to move away from the other.
Now such softening as this can hardly take place except
in inflammation. I will not say that it is impossible, but
I know that it is very rare. Posture alone, though very
long-continued, will not produce deformity of joints with
displacement of bones. I saw a gentleman who, in a half-
lunatic condition, sat for five years in the same posture,
and was credibly said to have never moved. At the end
of this time his knee-joints were contracted to a right
angle, and felt as if absolutely fixed ; yet they were not
deformed. Their bones had their right relations ; and,
after some weeks of extension with instruments, the
knees were straightened, and power over them was com-
pletely gained.
So, too, in a case told me by Professor Flower. A
man, whose skeleton is at Marburg, was encased by his
relatives for twenty years in a space in which he could
only sit with his limbs doubled-up, and in which he could
have had only very narrowly restrained movements of his
joints ; yet his hmbs did not become deformed, and his
joints retained their normal textures. And many a case
of hysterical joint, after being contracted for years, has
recovered without any error of shape.
Speaking generally, then, the presence of deformity in
a joint reputed diseased may be taken as certain evidence
that it was or is diseased, and the absence of such
deformity in a joint which has been long very painful, or,
in other characters, has seemed acutely diseased, is nearly
as certain evidence that there lias not been acute inflam-
NERVOUS MIMICRY. 207
mation ; unless, indeed, the shape of the jomt has been
maintained by careful treatment. A few weeks of acute
inflammation of a joint will almost certainly change its
shape and the relations of its bones, unless care is taken
to prevent the change; but even many months of mimicry
of acute disease will not produce or permit such change.
2o8 NERVOUS MIMICRY.
LECTUEE l.V.
If it seem strange to you that I should devote two
lectures to the subject of the mimicry of diseases of joints
— a subject which is usually dismissed with a few lines, —
let me say that I estimate its importance by what I know
to be its difficulty. I rarely pass a week without seeing
at least one very doubtful case, in which a diagnosis
cannot be made without a complete consideration of all
the symptoms discussed in the last lecture and of others
to be spoken of in this. For difficulties such as these,
two lectures may be tedious, but they are not superfluous.
Let us, then, go on with the symptoms of diseases of
joints, and see how the mimic may be distinguished from
the real. And the next shall be tlie wastings of limbs
near the aflected joints. This wasting occurs quickly
in nearly all acute inflammations of joints; more slowly
in tlie clironic inflammations. In tlie chronic it may be
from disuse alone : in the acute it is not so ; for it
is much more rapid and extensive than in any cases of
mere disuse. Compare, for instance, cases of fracture
of the thigh with those of acute disease of the hip, and
you will easily see how much greater is the wasting with
acute disease than with disuse alone. Kapid wasting may
be seen in the whole lower limb, especially in the thigh
and the nates, in all acute hip joint-diseases ; more slow
IVASTIXG XEAR JOINTS, 209
wasting in the painless scrofulous diseases ; less in the
chronic rheumatic. Wasting in the lower part of the
anterior and lateral muscles of the thigh is quickly
evident in acute knee-joint-disease ; only less quickly in
the chronic. In similar affections of the shoulder you
may see it in the flatness of the deltoid and of the mus-
cular coverings of the scapula ; and I think tliat tlie same
wasting occurs, in greater or less degree, in all muscles
near joints that are inflamed ; and the more quickly, the
more acute the inflammation. It is, I repeat, not a mere
wasting from disuse : it is far more rapid than that ; more
like wliat has been called acute atrophy of muscles, such
as may be seen in the swiftest cases of infantile paralysis.
This process of wasting is one of singular interest in
pathology. I wish I could explain it better than by
calling It reflex atrophy. It seems dependent on dis-
ordered nervous influence, and often appears proportionate
to the coincident pain, as if it were due to the disturbance
of some nutritive nervous centre, irritated by the painful
state of sensitive nerve-fibres.
But, however the wasting may be explained, it is,
unhappily for our present needs, not certainly diagnostic
of real joint-disease. You may find it nearly as marked,
tliough not so quickly progressive, in some nervous
affections as it is in acute inflammatory joint-disease. I
say you may, not you will ; and I cannot tell you in what
nerve- cases it will be found, in what be absent. I believe
it is in inflammations of nerves or in infiammations in-
volving spinal ganglia ; but I cannot tell. However, as
to diagnosis, you may fmd inflammation of the hip-joint
imitated, so far as pain and wasting are concerned, by
P
2IO NERVOUS MIMICRY, "
some painful affections of the sciatic nerve ; inflammation
of the slioulder-joint by painful affections of parts of the
brachial plexus ; and, more frequently, the wasting at the
lower part of the thigli, which is common with acute
inflammation of the knee-joint, is closely imitated in the
cases of certain knee-joints which are painful but not
inflamed. In the cases of this kind that I have seen there
was no sign of inflammation besides the pain ; no heat,
no adequate swelling — if, indeed, there were any at all ; the
patients were nervous or hysterical, and at the end the
joint though wasted was unchanged in sliape and structure.
You may hold, then, that, generally, the wasting of
the muscles about a suspected joint adds to the suspicion
that it is or has been inflamed ; but you nuist hold this
cautiously. You must expect to meet with cases, however
rarely, in which similar wasting attends pain at a joint
without inflammation. But, all the more because of
tliese cases, you may hold that if a joint has long been
very painful, and yet there is no wasting of the muscles
near it, it is not inflamed.
Let me tell you, by the way, tliat wasting at tlie knee
is conmionly produced and is always aggravated by the
wearing of elastic knee-caps or tight bandages. I liave
often been surprised to see liow quickly and to what
extent these pressures will produce wasting of muscles
and weakness, aggravating all the trouble consequent on
injuries and diseases of joints. They will in this way do
such damage, that, except ibr comfort duiing active
exercise, or for the purpose of reducing chronic thicken-
ings and collections of synovial fluid in joints, I believe
they ought never lo be used.
LAMENESS. 211:
Wasting, then, can be only cautiously judged as
among signs of real joint-disease ; it is too common in
mimicry to be a safe sign of reality. And so is another
sign ; impaired utility, or awkward use, such as we have
to observe most often in limping or other manner of lame-
ness.
The use to be made of this sio^n in diag^nosis is as of
pain: It may be absurdly exaggerated, caricatiu^ed ; and
by mere excess may prove itself unmeaning, as when a
patient in good general health, and with a cool or cold
well-shaped foot, has maintained for many weeks that it is
impossible to bear weight on the foot ; or when one, in
whose knee you can neither feel nor see any wrong, goes
limping as if with an utterly ruined joint. Here, as in
many other cases, inconsistency proves unreality.
The difficulty of diagnosis is far greater when there is
only slight limping or other impaired use of a joint. Here
you had better be very watchful and cautious, and err, if
at all, on the side of believing in real disease ; for the
cases are frequent, especially in children, and in serious
diseases of the hip, in which the first, and for a long time
the only, sign of real disease is some limping or other
erroneous use of a joint.
As you watcli the cases in which limping or some
manner of lameness is the chief or only apparent sign of
disease of a joint, you will find that some depend on, or
are ascribed to, mere muscular weakness of tlie limb,
some on a partial slight chorea. The former are often
associated with what Sir B. Brodie pointed out as some-
times occmTing in hysterical persons — a peculiar laxity
or limpness of joints. These are not difficult of di^ignosis;
r 2
212 NERVOUS MIMICRY.
if a really diseased joint is loose the disease is very plain.
The chorea! cases are more likely to deceive. In some
there is a sort of string-halt — a quick jerk-up of the heel
at every step, faintly suggesting some affection of the knee-
joint. Much more puzzling are the cases of slight chorea
of the whole lower limb in wliicli, as a ])atient walks, he
limps, and jerks, and throws-out liis leg, somewhat after
the manner of one with early disease of tlie hip. The
likeness is, indeed, not ver3Muarked ; yet in two cases that
I have seen it caused great fear : in one, because of the
importance of the patient ; in the other, because the
limping followed a blow, and a brother of the patient
was crippled with serious scrofulous disease of the hip.
In tliis case, too, the ordinary posture assumed in standing
was — by imitation, I believe — like that of diseased hip,
with the half-pelvis raised and the foot pointed. The
diagnosis of such cases may rest on tliese facts : if the
other usual signs of diseased hip-joint are absent or very
little marked ; if the limping movements are not careful
but quick and jerking ; if the passive movements of the
joint are complete and free ; if wlien the ])atient stoops,
so as to touch the feet with tlie hands, tlie fissure becomes
symmetrical ; tliere is no real disease. And this will
often ])e certified by choreal movements, such as twitchings
of the face or eyelids, told of or still present.
I liave thus gone througli the chief reputed and usual
signs ol" inllannnatory diseases ol' llie joints which may be
imitated by nervous affections closely enough to make a
diagnosis difficult. But other siuns i-c^nain which are
much more ran^ly i mi tilted, and never closely, exce])t in
some cases of complication of nervous affections with fever
SWELLING OF ^j 01 NTS. 213
or other accidentally concurring diseases. These are
swellino; and local heat and fever.
Xow, as to swelling of the whole or part of a joint,
its absence may be nearly enongli to prove that a joint in
which til ere is intense pain or other sign of acute
disease, or which has been long painful, or in any way
seemed long diseased, is only nervons. Inflammation of
a joint, either very acute or of long standing, can hardly
be found without visible or tangible exudation in the
joint-cavity or in the textures bounding it. But there
are many cases in which you cannot apply this ride for
diagnosis. A joint shrunken after long disease may re-
lapse into inflammation without renewed swelling, till
perhaps a residual abscess ^ appears. A hip-joint may bo
acutely inflamed without any discernible sw-elling ; so,
less often, may be a shoulder, the exudation being too
little to be felt. And, making more difficulty, swelling is
sometimes evident in a merely nervous joint ; not indeed
considerable swelling, but enough to make a mimicry
of real disease much more close. You may often see
this in the loose tissue by the sides of the ligamentum
patellse. The swelling sometimes appears due to such
slight exudation as may ensue in any neuralgic part ;
like the puffiness that may come-on in facial neuralgia, or
the swelling and congestion of the conjunctiva in some
cases of orbital neuralgia. Such swelling is commonly
transient and capricious, and the fallacy may be detected
by observing that, at its greatest degree, it is not, even
after long time or many repetitions, nearly proportionate
to the pain or duration of the disease. For a joint which
* See Essay on llesidual. Abscess.
214 NERVOUS MIMICRY.
is intensely painful, with acute inflammation, or with ul-
ceration of cartilages, should be, if not at first, yet soon
after, considerably and always swollen.
In other cases, swelhng of a nervous joint may be
due to accidental conditions. For instance, repeated
blisterings or repeated paintings with iodine will give, for
a time, sucli thickening and ])ufiing of the subcutaneous
tissue about a joint as may be very deceptive when added
to the otlier signs imitating inflammation of tlie joint.
So, again, I have seen such a condition in a very marked
degree produced by the long-continued use of ice about
11 painful joint.
On the whole, then, the absence of swelling makes it
very unlikely that a joint is really diseased ; so does the
presence of only a trivial swelling when the nervous and
muscular signs of disease are acute or of long standing ;
and when swelling exists it must not be counted as add-
ing to tlie probabihty of real disease, unless it persists
and is independent of such accidents as I Jiiave already
named. And remember tliat a sensation of swelhng is
not unfrequently complained of when no swelling what-
ever exists. It is just one of tlie erroneous sensations to
which nervous persons are prone, as they are to sensa-
tions of unnatural fulness and of weight for which there
is no substantial reason. Such a mere complaint of
swelling will not deceive you if you compare the sus-
pected joint with its fellow.
But, after all, the sign most to be relied on for diag-
nosis between real and nervous disease of joints is the
temperature. It is so iiiipoiLanl to estimate it accurately
that I cannot too strongly urge you to be always study-
HEA7 OF JOINTS. 215
ing it. You should feel Avitli a broad surface of your
hand every joint very watchfully, comparing each that is
supposed to be diseased with its fellow supposed or
known to be healthy, till you learn, as you certainly
may, to detect even a small difference of temperature in
even a small part of a joint.^
Wlien you have learnt to feel accurately the heat of a
joint, you may safely rely on it for some certainties in
diagnosis. A joint that feels all over cold, or cool, or
not above its natural temperature, is not an inflamed
joint : whatever may be the other signs of inflammation
in it, it is not inflamed ; you may rely on this. In the
hip and shoulder, however, this test of temperature is not
easily ' applicable. The thickness of various textures
covering those joints is too great for additional tempera-
ture to be transmitted through them. But in the knee
and elbow, and other smaller joints, even those of the
fingers and of the tarsus and carpus, the test is easily ap-
phed and sure ; and remember always, in using it, that
in most persons the front of the knee-joint, and, in a less
degree, the back of the elbow, are habitually cool to the
touch — cooler than the arm and leg ; and that in many
the feet are rarely v^arm in health. These local varia-
tions, however, can lead to no confusion if you follow the
rule — which, for other reasons as well as this, ouglit to
be never neglected — of comparing every suspected joint
with its fellow. Besides, always compare the tempera-
ture of the joint with that of the rest of the limb, for the
rest of a limb may be, through disease or long defective
^ Mr. Tlilton strongly insists on the value of heat as a sign of local in-
flammation. ' Lectures on Pain and Ilest,' 18G'i. [Ed.J
2i6 KERVOl/S MIMICRY.
nutrition, cold ; and if one joint in it be always not cold,
though it may not be fairly called hot, this may be
through its being inflamed. I repeat, then, a joint which
is not above its natural temperature is not an inflamed
joint. But observe, besides, some rules within this rule.
A joint when first exposed for examination may feel
over- warm. Tliis mav be due to its havinc^ been
very warmly wrap])ed, or thickly covered with w^ater-
dressing, or in some other "way hindered from cooling to
its natural temperature. Wait, therefore, and observe
whether, after a fe^v minutes' exposure to cool air, the
joint has become of the same temperature as its fellow or
as the rest of the limb. If it have, you may be very
nearly sure it is not inflamed ; or your suspicions tliat it
is inflamed may increase with the time during wdiicli its
cooling is delayed. Frequently only a part of a joint is
inflamed, and in this case the morbidly liigh temperature
can be felt only over the inflamed part. This limitation
of a sign of inflammation which one might suppose easily
diffusible is a striking' fact. It is the same with the
swelling, which, especially in scrofulous inllammations of
joints, is often limited to a single portion.
Not rarely, wdien you feel a joint quite cool, the
patient will tell you that it is, nevertheless, at times very
hot or burning liot, and that with this heat it swells and
l)ecomes red. Such cases are common amona' those in
which the consequences of sprains and other injuries are
very prolonged in nervous persons, or even in healthy
])ersons whose joints have been, too long treated with
cold douches or too long kept at rest. These joints are
commonly reported as getting very hot every evening.
HEAT OF JOINTS. 217
and as being subject to painful lieats, tingling, and burn-
ing. In any such case you may decide that the joint is
not inflamed. If it were, it should be over-warm all day
and all night. The occasional heat is only due to flush-
ing, such as some nervous people have in their faces after
their meals, or such as women commonly have at the
time of ceasing to menstruate. I call it flushing, not
blushing, for it is not associated with any mental state;
indeed, it may seem strange that, among all the nervous
people with joints that are the constant objects of their
attention, one never sees blushing of the skin over them
Avhen they are being looked at. All such turgescence
and transient heat are consistent with complete absence
of organic disease. Doubtless tlie same thing may
happen in inflamed parts ; they are sometimes hotter
than at other times, more swollen and more painful,
having periods of exacerbation ; but then they are never
of natural temperature — they are always more or less
too hot. It is very difierent with the mimicries of in-
flammation in joints ; here the over-heat is only at times,
at night or at some nearly regular hour, or after exercise
or fatigue. A joint wdiich is cold by day and hot by
night is not an inflamed joint — ^that is certain.
The certainty of the diagnosis based on coldness is, if
possible, increased by coincident duskiness of the skin —
by its having the dull purplish tint which is commonly
called blue or a dull pink. Such colours may be seen at
joints long inflamed, but in these cases they arc as-
sociated with over-heat ; when they are associated with
coldness, they are characteristic of anything rather than
inflammation. Besides, witli inflammation the colours of
2i8 NERVOUS MIMICRY,
over-fulness of bloodvessels are only at the inflamed
parts ; with congestion in cold nervous joints they are
commonly much more widely diffused.
Lastly, as to fever associated with a supposed inflam-
mation of a joint. It may help you to diagnosis in some
few cases, chiefly in those in which the pain is very
severe, or in which there are other signs like any of those
of acute inflammation. For no very acute inflannnation
of a considerable joint can exist without fever ; and
therefore, wdien a patient's general temperature is normal,
5'Ou may be very doubtful, to say the least, whether an
intensel}^ painful joint is inflamed. But the reverse is
not true ; the temperature may be frequently or habitu-
ally high, though a suspected joint be only neuralgic or
in some other mimicry of acute disease. For the patient
may be tuberculous, or, witli some casual illness ' may ,
have a higli temperature, or he may be recently con-
valescent from acute fever. Moreover, a very slight
degree of inflammation in a joint in a very nervous
person may be associated with a disproportionately high
general temperature. This is in accordance with a
general rule already mentioned — that in those with alert
and mobiki nervous systems a slight local inflammation
may produce or be associated with a great increase of
general temperature. In similar persons, fatigue or
])assing excitement will raise the temperature to 100°, or,
I think, to 101°; and in their convalescence from acute
illness — a condition in whicli nervous mimicry, as well as
real joint-disease, is apt to a])pea]' — they liavc widely
variable temperature. You must therefore liold, as a
general rule, that, in veiy nervous persons, the tempera-
JVERVOUS MIMICRY. 219
ture must be studied many times, and with circum-
spection, before it is counted as an addition to the
evidences of their having real joint-disease. Within the
last few days I have been very nearly deceived in such a
case. A gentleman, about thirty, had what he described
as frightful paroxysmal pain in one knee — pain such as
might have been in the most acute inflammation of the
joint; and there were some heat, some swelling, and a
general temperature of 101°. These things had ' come
of themselves ' within three or four days, and the patient
looked very ill. Of course he was treated cautiously ;
and all subsided so quickly as to make it sure that no
serious, if indeed any, organic disease had existed. It
was a nervous mimicry ensuing upon excessive and un-
successful work.
220 AERVOUS MIMICRY,
LECTUEE Y.
ON NERVOUS MIMICRY (XEUROMfMESIs) OF DISEASES OF
THE SPIXE.
For tlic next group of cases of neuromiinesis, or iici\'oiis
mimicry, I will take those of Diseases of the Spine. They
are nearly as frequent as the imitations of diseases of the
joints ; and their diagnosis, of wliicli alone I shall speak,
may be studied in the same way ; weighing tlie evidence
of each of the chief local symptoms, and then adding or
subtracting whatever may be gathered from the patient's
constitution and the history of the case.
The chief things to study in the spine are pain, stiff-
ness, weakness, and deformity.
As to pain — spineache and backache, often not dis-
tinguishable, are perhaps the most common sufferings of
the whole class of hysterical and other sucli nervous
patients. Few escape them. But, then, similar pain is
so common in (^ther patients besides the nervous, and is "
ibinid in so many and so various diseases, that pain alone
can rarely decide a diagnosis. T must leave out of the
question all tlie 'backaches' that belong to lumbago,
rlieumatic gout, uterine, ovarian, renal, and other maladies,
and try to answer lor you only tins : Are there any
characters by which we may distinguish between pain
that signifies real disease of the spine and pain that
mimics sucli disease ?
PAIN IN THE SPINE. 221
Well, we cannot always do so. There is no ]:)ain
which is characteristic of real spinal disease — no manner
of pain which may not be closely mimicked ; but, in
many cases, the nervous mimic-pain lias characters which
are not all found together in real disease of the spine.
Nervous spineache is often described as very severe —
raixinsf, rackino- as if the back were breakinsf, and so on.
Now, such pain as this does not occur in real spinal dis-
ease, unless when the pain of some slight disease is im-
mensely exaggerated in a nervous constitution, or in the
acutest form of inflammation of the vertebra? — a very
rare disease, always associated with serious general illness
and impaired mobility of the spine. If tliere be no con-
siderable attendant illness, an intense and horrible pain
in or at the sphie does not mean serious disease of the
spine. I do not say that such pain is always merely
' nervous ' when it is the only wrong complained of. It
may be due to aneurism, or cancer, or to some distant
malady in a nervous constitution ; but, unless in the two
cases I just now mentioned, it is not a sign of spinal dis-
ease.
And this neo*ative becomes the strono;er when witli
such a pain there is excessive tenderness of one or more
parts of tlie spine. Some tenderness on pressure of
sphious processes may be found with real disease of the
spine or cerebro-spinal membranes ; but excessive tender-
ness is not, unless in the rare instances of periostitis of
one or more spinous processes, which are usually asso-
ciated, I think, witli syphilis. It is rather characteristic
of merely nervous disorder, of the so-called spinal irrita-
tion, and usually you find it, not at one, but at two or more
222 NERVOUS MIMICRY.
parts of the spine, most frequently between the scapulae
and at the loin. At these tender spots the nervous
patients cannot bear to be touched ; they flinch and
writhe when the fniger taps or presses them very gently.
You may be nearly sure that there is no disease of the
spine when j^ou see this, or when the tender parts of the
spine are not painful in moving or in coughing or
sneezing. And you may be quite sure, I believe, when a
gentle bloAV or pressure produces more pain than a hard
one, or when you find the same pain or flinching if the
skin over or near the spine is pinched without pressing on
the spine itself.
Again, the merely nervous pain is usually variable,
*t]iough it may be never wholly absent ; and its variations
seem to be more dependent than those of real diseases
are on disorders of distant organs, as the ovaries or uterus,
the colon or rectum. In these variations the pain may
seem paroxysmal, but I thiok it is not often so of
itself.
Another usual character of this pain is its frequently
extreme increase in fatigue, not only in bodily fatigue, as
in long sitting upiight or standing, but in long occupation
of any kind, even in mental occupation if it is not very
am'ceable. With this character, also, it is common for
the pain to be accompanied by nausea or even vomiting,
and it is a nearly sui-e sign of merely nervous disorder if
pressure on the spine jn'oduces shivering or nausea, or a
feeling of going to be sick.
And, lastly, it is a sign of nervous pain alone if llie
pain has lasted many weeks or months, and nothhig has
come of it ; no innnobility of the spine or ribs, no
PAIN IN THE SPINE. 223,.
paralysis, no fever, or wasting, or great disturbance of the
ijeneral health.
I think you may be sure that a patient in whom you
find all or most of these characters of pain in the spine
has not spinal disease. But you will find many with pain
like enough to tliis to excite suspicion, though not nearly
like enough for conviction ; many in whose cases the
dia2[nosis must rest much more on other si^ns than that
of pain. Among these, let me warn you that the greater
danger is that of thinking cases to be mimicries of disease,
or ' muscular ' or ' only rheumatic,' when they are really
serious organic diseases of the spine or of parts within it.
I will try to diminish the danger of being wrong in either
direction by mentioning some of the more frequent groups
of cases difiicult of diagnosis.
The curvatures of the spine that occur frequently in
young persons are often painless, are seldom very painful,
and have no characteristic pain : yet pain of any kind
should always lead you to examine for curvature, and to
suspect, if there be curvature already, that it is increasing.
And the same rule should be observed with older
patients ; for it is not extremely rare for lateral curvature
to begin after middle age, nor at all rare for it to increase
at any period of life. In either case there may be pain,
for which the spine should be often looked at for signs of
disease more characteristic than the pain alone can be.
Aching spines are common in men with very nervous
constitutions — in such as might be called hysterical with
as much justice as many women are. Especially they are
common in such men from thirty to fifty or more, and in
women who retain their nervous or completely hysterical
224 A'ERVOUS MIMIC RV,
constitution to tlie middle or later times of life, and in
wliom, very probably, it is mingled with gout. There are
far more cases of this sort in the cultivated classes of
society than you are likely to suppose : men and women
of mature or post-mature age, with spines whose nervous
achino's disable them from active life — at least from
active bodily life ; for in some of them the mental life is
as active as if it really took tlielr whole nervous force for
its own use. They suffer severel}^ are painfully fatigued
with exercise, have no comfort unless when tliey are
lying down or reclining witli tlieir backs firmly supported ;
even slight manual work tires them : and yet in some of
them the. mind seems incapable of fatigue, or it only tells
its fatigue in some increase of tlieir spineache, or in
feelings of nausea or vomiting. In many of these cases
the diao'nosis is not difficult : the nervous constitution is
very strongly marked, and, after montlis or years of
weariness and ache, you find the spine as straight, strong,
and pliant as ever.
And yet among these are the chief cases in wliichyou
must be on the watcli, lest \-ou overlook a really diseased
spine ; for, among elderly persons, you may not only, as
I have said just now, And cases of be^'innini]!: or increasing:
lateral curvature, but, occasionally, one of disease leading
to angular curvature, setting in very insidiously like a
case of nervous pain oi* chronic rheumatism. The first
sign of this is, usually, a constant aching, which is some-
times even severe, fixed to one part of the spine, or
radiatinir Ironi it, oi* exlcndinij' round the sides; and
there may be some; tendei'uess. ]jut, chiefl}^, you may
know them by the diminished mobility of the affected
PAIN IN THE SPINE. 225
part of the spine and of the adjacent ribs. The patient
holds the affected part of the spine as still as he can,
Avhen he turns or bends. If he coughs he does it care-
fully, and sneezing is very painful. If the dorsal portion
of the spine be affected, the corresponding ribs scarcely
move ; if the cervical, pressure on the top of the head is
often painful. After some few weeks of such pain,
yielding of the spine may become evident. If the patient
is the first to notice it, he feels himself stooping, or
obliged to support himself with his hands, or not so tall
as he was ; and, when you strip him, you may find two
or three vertebral spines projecting in an incurable
angular curve.
These things, you see, are much the same as those by
which you recognise the progress of many cases of caries
of the spine in children and young persons, and I suppose
that this disease in elder persons is of the same kind.
But I have^ not yet seen a fatal case or one examined
after death ; and I have seen only one in which abscess
was associated with the angular curvature.
You may make anotlier group of cases from other
patients, in whom a strain of any part of the spine is
followed by a very long abiding pain. Some of these
wiU tell you that at the strain they felt, or even heard,
something crack, and that they have had pain and weak-
ness ever since — aching, wearing pain, increased by
exercise, or in certain postures. Here again I must advise
caution, especially when the injury is recent. In a large
majority of these cases, the long-abiding pain and other
signs of spinal disease may be referred to the same nervous
^ See Essay on Senile Scrofula,
226 NERVOUS MIMICRY.
mimicry as we see in those whose sprained knees or ancles
remain for weeks or months painful and weak, yet without
disease. But in some the pain continues because, as may
happen in an injured joint, the injury has been followed
by inflammation ; and this may be of serious form. The
pain alone \vill not prove it ; but you may be afraid of it
when you find diminished mobility of the spine or ribs,
great pain in coughing, greater in sneezing ; and much
more afraid when you find occasional or constant fever,
and loss of weight and general strength. In short, for
the diafijuosis between the real and the mimic diseases
following injuries of the spine, you may study by the
rules which are more easily learnt in the similar affections
after injmies of the joints.
It is happy for our need of diagnosis that the impak-
ments of the mobility and strength of the spine are more
significant than its pains. The spine or any part of it,
when really diseased, is often stiff and weak, thougli
other signs of disease are absent or ill-marked ; in the
mimicry the mobility is often perfect, though other signs
are vehement.
Fixity of the spine or of any part of it is extremely
rare in any nervous mimicry. I will not say that it is
never seen, but it is so rare that when you find a patient
carefully — not with muscular spasm, but with care —
holding his head and neck or any part of his back very
still, turning himself or bending cautiously, you must look
for disease of the spine. There may be muscular rheu-
matism, or inflamed cellular tissue, or abscess, or whatever
else may give pain in moving ; but there is not likely to
be only a nervous mimicry of spinal disease.
WEAKNESS OF THE SPINE. . 227
Tliis fixity of spine is the more significant of real
disease the less the attendant pain. Still more so is it
when the ribs connected with the suspected and stiff part
of the spine are also motionless or too little moved in
breathing, and when the breathing is chiefly diaphragmatic.
There may in this case be disease within the chest —
perhaps the pleurisy that is often associated with acute
inflammation of the dorsal part of the spine ; or it may
be very imcertain what disease of the spine there is ; but
it is very nearly certain — as certain, I tliink, as any
diagnosis of unseen disease — that there is not a mere
mimicry. Whenever you are told of ' spinal irritation,'
^ hysteric spine,' or whatever else an unreal disorder at
the spine may be named, look carefully to the mobility
of the spine and ribs ; if it is impaired, look much further
before you venture to conclude that the malady is only
nervous.
The very opposite state of the spine, in which it is all
limp, so that when the patient tries to sit up, he, or more
often she, bends or tumbles this way or that, like a baby,
is nearly certain to be without organic disease. There
may be real paraplegia ; if there be not, you may believe
the weak tumbling spine is in itself healthy, though it
may contain an idiotic spinal marrow ; as a good skull
may hold very foolisli^brains.
A feeling of weakness or giving-way at one part of
the spine is ambiguous. It is often complained of in
iieuromimesis ; but it is also often present in carious or
other real disease of the spine. It must always be con-
sidered likely to be a grave symptom if the patient
habitually, and almost unconsciously, helps to support
q2
228 NERVOUS MIMICRY.
tlie spine with the hands or elbows as lie sits. Of course
this self-supporting posture may be either iniintentionally
or on purpose imitated in a nervous mimicry ; but it so
often has a real meanino- that it must not be made lidit
of, unless all other evidences of mimicry are clear.
You will often find that with this weakness of one
part of the spine there is some distress in moving it. The
patient does not wilhngly rise or turn in bed, and if he
walks he does it slowly, often stooping or leaning forward^
going stiffly or shuffling, not staggeiing or unsteady
unless the spinal marrow be involved in the disease.
This sign is, I think, less rarely mimicked than the last ;
the two together are weighty evidence for real spinal
disease, and if defective movement of the ribs be added
you had better believe that the spine is certainly diseased ;
whether with struma or rheumatism, or whatever else.
The other leading sign for the diagnosis between real
and mimic diseases of the spine is in its shape. Is it
mis-shapen, wrongly curved, or in any w^ay deformed ?
If so, it probably is or was really diseased ; and yet even
here is room for error.
An angular curvature of tlie spine — I mean such
backward outstanding of one or more vertebrai as is due
to thinning or loss of substance of tlieir bodies or inter-
vertebral discs — is, I believe, quite inimitable by any
nervous or muscular condition. But in not a few persons
you will find tliat one or two vertebral spines naturally
project a little, or are ])laced a little on one side of the
exact line or curve in which tliey should be. This is
most often seen in the lower dorsal and lumbar part of
the spine ; but it is so httle like disease that it would be
I
CURVATURE OF THE SPEXE. 229
unnoticed if spine-ache or some fright about curved spine
did not call attention to it. I think you will seldom
have any difficulty in distinguishing this natural error
from any effect of disease.
A lateral curvature of the spine may be imitated by
disorderly muscular action ; not, indeed, perfectly, yet
near enough to be often deceptive. Spasmodic wry-neck
is well enough known, and may imitate the distortion of
considerable disease of the cervical part of the spine.
Lateral curvature of the dorsal and lumbar parts from
similar muscular disturbance is much rarer, but you may
expect to meet with it ; and you may often detect the
mimicry by noticing that the curvature lias formed very
quickly or even suddenly, and has become marked or
extreme in so short a time as could not have sufficed for
a real lateral curvature. A few days will make an
imitation-curvature stronger than as many months will
make a real one. Besides, the mimic curvature is not a
perfect likeness. It is sometimes single, though very
marked ; real lateral curvatures, if very marked, are at
least double ; and the vertebrce are little or not at all
rotated, as they are in well-marked real lateral curvatures.
If tliese signs of distinction are not enough, ether' or
chloroform will help. You can straighten the mimic cur-
vature when the muscles cannot act ; you cannot so
straighten a real curvature.
Other deformities of the spine may be imitated by
hysterical and other such persons. The spine may be
rotated without curvature, or drawn to one side, so as to
go-up obliquely from the pelvis ; or in those wdth very
weak, limp spines there may be, w]ien their trunks should
230 A'ERVOUS MIMICRY.
be erect, an appearance of an uniform posterior curvature.
Eut I believe you may easily detect the mimicry in all
these. Most of them are extravagant, going beyond
almost any real deformity of the kind that such a patient
could have ; and, almost always the wrong may be
righted by putting the patient in some unusual position,
as lying very flat on the back or front, or with the hands
touching the feet, or hanging on a swing. By these, or
the like means, you may out-trick the trickery of the
muscles.
One tiling more : you will often be consulted about
irregularities of the scapulo3. Lady-mothers are always
-watching their daughters' shoulders (happily for sons,
their's are neglected), and any unlikeness of the shoulder-
blades, such as one being higher, or further back, or
smaller, than the other, is an alarm of curvature of the
spine. The alarm is usually premature or false. A
difference between the scapulae may be due to muscular
trick or awkwardness, or overwritino' witli the shoulder
pushed-up, or any of several other things ; but if you
cannot see in the spine or ribs some wrong curvatme,
rotation, or other mis-shape, tlie position of a scapula does
not prove it. Still, these and tlie like cases are often
liard to advise in, for the higher education of girls is apt
to promote all tliose things whicli are favourable to tlie
production of both real and mimic diseases of the spine.
Wearisome mental occupation ; long writing, with the
spine twisted and tlie shoulder thrust-up ; long upright
sitting, fatiguing drill and calisthenics ; denial of most
natural exercises, and of rests at will, or in any easy
posture which is thouglit luigraceful — these and the like
PARAPLEGIA, 231
things in the education of girls are equally favourable to
the development of the nervous constitution, and to the
production of various backaches, and to the deforming
of the spine. You must do your best in all such cases to
discern what is real, and what is mimic. I can give you
no general rules about them.
In trying to teach the diagnosis between the mimic
and the real diseases of the spine, I have purposely
spoken of only those signs which are usual in the early
stages of the real diseases, for it is only in these early
stao^es that the diagnosis can be difficult. A well-marked
unalterable deformity of the spine leaves no question
about mimicry, unless it be about the nature of some ac-
companying pain. The appearance of swelling, like a
chronic abscess, by the side of the spine or in the groin
may not make you sure that the spine is diseased, but at
least it answers any questions about mimicry ; and so do
hectic fever, and habitually high temperature, and
constant wasting. These things need no teaching : but I
must speak of one more set of symptoms — the paralytic,
the losses of sensation, or more frequently of muscular
power in the limbs, — which may be associated with
diseases of the spine. I must refer to them, though I
believe they very rarely give help in diagnosis. For
paralysis due to disease extending from the spine to the
spinal cord is rare, except in the later stages of disease,
and of these the evidence is clear enough without the
paralysis. And when paralysis happens in what you
may suspect to be the beginning of disease of the spine,
it will very seldom help you, for you cannot tell that
which is due to disease commencing in the spine from
232 NERVOUS MIMICRY.
that which is due to disease commencing in the cord.
And, lastly, if you are suspecting a mimicry of disease of
tlie spine, here, again, paralysis may not help the diag-
nosis, for itself also may be mimicry.
Thus your only surety for right diagnosis between
real and mimic affections of the spine is in the examina-
tion first of the spine itself, and then of the patient's con-
stitution.
TUMOURS.
'jj
LECTURE VI.
JS^ERVOUS MIMICRY (nEUROMIMESIS) OF TUMOURS.
I SAID in my first lecture that I should treat of
nervous mimicry from only the surgical point of view.
From even this limited view many things may be seen
which I must omit, as mimic paraplegia, mimic tetanus,
mimic aphonia, and others. Concerning these you may
find guidance to diagnosis in the best works on Hys-
teria. I will take now a set of cases that have been
much less written of — the nervous mimicries of tumours.
Of these there are tliree principal forms : the muscular
or phantom tumours, the imitations of aneurisms, and
those of cancers.
In what are called phantom tumours the imitation is
due to the swelling of part of a muscle during contrac-
tion. This part, swelling and becoming harder than the
rest, feels something like a smooth round or oval tumour
or cyst, placed in or between the muscles. The rest of
the muscle feels natural, whether relaxed or contracted.
In the former state the apparent tumour is most distinctly
felt ; in the latter state it may be nearly concealed, as
if sinking in the muscle.
This condition is alto^'cther a strano;e one — not
imitated, so far as I know, in any other state of muscle,
unless it be in crimping, or in tlie flickering and
passing contractions of dying muscles, or in the lumps
234 NERVOUS MIMICRY,
wliicli, it is said, may form in those that are struck
soon after apparent deatli in any acute fever. If it may
be compared witli anything in hving muscles, it may be
with cramp which draws them into knots or himps ; but
there is no pain in phantom tumours as there is in cramp.
Whatever it may be, the condition seems due to er-
roneous nerve-force in the muscle ; for one form, the
phantom tumours of the abdominal muscles, is most
frequent in evidently hysterical women, and in other
cases that I have seen there was certainly an abnormal
state of nervous system, and in others it Avas very probable.
Three cases which I chance to have seen lately may
illustrate the disease.
In one, a gentleman about sixty years old, came to
me for a tumour, as he thought, in his right calf ; and I
found in the mid-substance of his gastrocnemius what
seemed to be a roundisli smooth lump, nearly two inches
in diameter. While examining it I seemed sometimes to
lose it altogether, as if it slipped aAvay or receded into
the deptlis of the calf: and then, after a time, I con-
vinced myself that it had no real existence as a timiour ;
that it could be put-out by friction, or by complete re-
laxation of the muscle, or in some postures of the limb.
It seemed due to defective or disorderly nerve-force in
the muscle ; for tlie patient liad been slowly becoming
very feeble in liis lower limbs,and had the slow, sliort-
stcpping, shulUiug gait, and weak, monotonous voice and
unclear speech, wliich, I suppose, betokened senile de-
generacy of nervous centres.
The second case was that of a clergyman, about
thirty, who came for weakness of tlie lower limbs and
PHANTOM-TUMO URS. 235
frequent falling, wliicli he was disposed to ascribe, in
some measure, to a 'lump' near his left knee-joint, and
another, less prominent, near the right. His calves were
very large and muscular ; his thighs small and weak ; ^
and the lumps were swellings of the lower ends of the in-
ternal vasti, when, with the other wasted and weak muscles
of the fronts of the thighs, they contracted. They did,
indeed, look something like smooth oval cysts by the
knees ; but they subsided so quickly and completely
when the action of the muscles ceased, that there was no
difficulty in seeing what they were. And here, too was
nervous defect.
The third case was that of a lady about sixty, who
had had a tumour on or over her left parotid. This had
been removed about eight years before I saw her, and in
the operation the facial nerve was injured, so that the
left facial muscles were partially paralysed and subject to
occasional twitchings during emotion. In the last year
there had been a renewed superficial growth over the
parotid, and with this an increase in the facial twitches.
But what much more alarmed the patient was the ap-
pearance of a tumour, as she thought, below the left
clavicle. This was the clavicular portion of the pec-
toralis major, partially contracted and hard, and perhaps
miide irritable, or more attractive to the alarmed atten-
tion, by the frequent twitchings of the platysma. All
appearance of tumour was spoiled by raising the arm
above the head ; when the muscle was completely
relaxed it all felt as soft and natural as its fellow.
^ In some of its features this case resembles the pseudo-hype rtrophic
muscular paralysis of Duchenne.
236 XERVOL'S MIMICRY,
This last patient was over-sensitive and excitable, and
probably augmented the disorderly action of her muscle
by her too careful attention to it. The direction of the
mind alone may, indeed, suffice to make, in some persons,
a distant imitation of a tumour in a muscle. I once saw
a gentleman who was possessed with the fear that he
would die of psoas abscess because his brother did ; and,
for a day or more, he was constantly pressing his abdomen
towards the psoas by the spine, till a part of his external
oblique abdominal muscle had become so irritable that it
Iiardened and swelled at every attempt at pressm^e, and
felt somethino; like a tumour. All this ceased when it
was completely relaxed by posture. But in ordinary
cases the mind seems to have nothing; to do with the
pliantom. The first two cases w^ere in very ordinary
gentlemen, and mental influence could not fairly be
assigned as any reason for their mimicry of tumours.
There should be no great difficulty of diagnosis in tlie
ordinary cases of this kind. A real tumour that hes deep
in or beneath thick muscle may be pressed down beyond
clear toucli when the muscle contracts and hardens ; and
it may l^e difficult to feel the boundaries of a venous
tumour or na3vus in a deep or thick nuiscle. But these
tilings will not mislead you if you "will study the case
long enough to be clear as to the inconstancy of appear-
ance. If in one miiuite an apparent tumour is under the
finders and in the next mimite is i^one : if it shifts from
one part of a muscle to anolher, as one set of fibres after
another contracts ; if it wholly disappears when tlie
nmscle is long relaxed, — tins is a phantom, a mere mimi-
cry of a tumour.
ABDOMINAL PULSATING TUMOUR. lyj
There is rather more difficulty in some of the cases of
phantom tumours which occur in the abdominal muscles
of hysterical women. These are sometimes large, hard,
and more nearly fixed in place, size, and form, than those
in the limbs, and they may be deceptively complicated
with disorderly states of the intestines, or the aorta, or
other abdominal or pelvic organs. But in any case,
liowever difficult of diagnosis, ether or chloroform will
bring all the help you need. With complete insensibility
and muscular relaxation all signs of tumour disappear — -
the phantom vanishes.
Let me tell you the most striking case of this kind
that I have seen. It was in a liealthy- looking woman,
about thirty years of age, in Sitwell ward. I admitted
her for a tumour in the upper part of the abdomen, be-
hind, as it seemed, the first division of the left rectus ab-
dominis muscle, but larger tlian that seemed. It was
roundish, firm, nearly hard, constant in its characters
and place, often painful, and distinctly pulsating, like an
aneurism. A light bruit was audible in it. Of its
history I only remember well that there was nothing to
lielp in diagnosis. In full medical and surgical consulta-
tion with my colleagues, the questions were whether
there was a tumour with pulsation communicated from
the aorta, or an aneurism. If a tumour, where, or in
what ? If an aneurism, of what artery ? The opinions
were many and various, partly, perhaps, because the
examination was painful, and, therefore, possibly, incom-
plete. So one day I gave the patient chloroform, and
the tumour, the aneurism, and the doubt dispersed ; they
were all phantoms.
2sS • NERVOUS MIMICRY^
This case, in which an abnormal nervous condition of
a muscle and of the abdominal aorta appeared to be com-
bined, may lead us to the next set of mimic tumours —
the imitations of aneurisms by what I suppose to be
iibnormal nervous conditions of arteries. The evidences
of this condition are, indeed, not complete ; but, at least,
tjie mimicry of aneurism is more frequent in persons of
nervous constitutions than in any other. It is sometimes
associated with well-marked hysteria, and the likeness of
aneiu:ism often varies according to the state of tlic
patient's nervous system.
This mimicry is most frequent in the abdominal aorta,
in which it has often been described as a nervous abdo-
minal pulsation ; but, so far as I know, it is not described
as occurring in tlie subclavian, innominate, or carotid
arteries, though in these it is not very rare, and sometimes
is not easy of diagnosis. The chief characteristic of tlie
mimicry is that the affected artery feels mucli larger than
it should be, and pulsates largely at least in one direction,
dilating obtrusively, and often so much more visibly than
in an ordinary person that it is hard not to believe that it
is largely dilated. And yet there certainly is no con-
siderable dilatation ; it is rather as if the arterial walls
w^ere thin and had too little muscular resistance, as we
might suppose them to be in a condition of partial
paralysis of their muscular tissue. In the most marked
case of imitation of abdominal aneurism that I have seen,
examination after death found no disease. A lady of
very nervous constitution had suffered severe sea-sickness
in a ])assage to Ireland. The sickness scarcely ceased
during her stay there, and was aggravated on her return-
IMITATION OF ANEURISMS. 239
voyage, after which she continued vomiting nearly all
her food, till, at the end of some weeks, she died ex-
hausted. During these weeks there was so large and
strong a pulsation in her abdominal aorta that some were
convinced that she had abdominal aneurism. As she lav
on her back, one could see the artery pulsating behind
the abdominal wall. It raised the hand laid on it, thrust-
ing up the fingers with a firm throb and a thrill, and a
low but distinct blowing was audible when the stethoscope
was lightly pressed on the artery. Yet there was no
aneurism. After death the artery was found absolutely
healthy in both size and structure.
I say again, I do not know what is exactly the state
of the arteries in these cases. There are few opportunities
of examining them after death ; and I have heard of none
that told more than the one I just now mentioned to you.
But, clinically, these cases are well marked. The artery
feels large, wide, and full ; but soft and compressible, or
even, if one may so call it, puffy, without any of the hard-
ness or stiffness felt in aneurisms. The pulsation is full,
but rather soft, like that of an artery in the reaction
after large loss of blood ; and, which is chiefly character-
istic of the absence of dilatation or aneurism, the extra-
full pulsation is in only one direction. There is no
unusual lateral dilatation ; the too-much throb is only
forwards.
The likeness to aneurism in these cases is sometimes
greater than could well be expected ; for many things be-
sides the excess of pulsation may contribute to it. In tlic
abdominal aorta an unusual appearance of prominence
may be given by an unusual anterior curve of the lumbar
240 NERVOUS MIMICRY.
vertebra3 ; and by thinness, with concavity of the abclo-
niinal walls, and emptiness of the stomach. Hardness or
toughness of the pancreas, or of lymph-glands about the
aorta, may yet further hicrease the likeness to abdominal
aneurism.
In like manner, the imitation of subclavian aneurism
is made more marked when a nervously pulsating sub-
clavian artery has glands beneath or about it ; and still
more when it lies on a cervical rib, and is somewhat
raised and, I suppose, widened. And the imitation of
upper carotid aneurism is added-to by the very bulbous
form of the first portion of the internal carotid and its
occasionally tortuous course. That of the lower carotid
aneurism may be augmented by enlargement of an over-
lying lobe of the thyroid gland.
With all these helps to difficulty you may sometimes
be troubled in the diagnosis of a mere nervously pul-
sating artery. In nearly all the cases I have had to see
aneurism was suspected ; but a few rules will ensure
against error. The nervous artery has no lateral expan-
sion ; it does not open tlie finger and tliumb when they
laterally compress it lightly ; you can trace the straight
lines of its sides ; in the abdominal aorta the pulsation is
lost, or nearly lost, when the patient sits leaning forward ;
in the other arteries, by relaxing the parts over tliem.
Always the artery has at least its natural softness and
compressibility ; commonly it lias more. There are no
paroxysms of pain ; and if tlie case has been watched for
months, or even years, tliere is little, or more often no,
increase of size. On tlie other Iiand, the extent of artery
wliich may feel dilated may much increase, so that we
CANCER. 241
may see and feel, for instance, an abnormal throbbing in
the innominate, carotids, and subclavians of the same
patient — a state unheard-of in aneurisms.
Before leaving this subject, I just mention to you the
cases in which you will find, in certain patients, anemia,
enlarged thyroid gland, protruding eyeballs, and pulsating
carotid arteries. The study of these cases might clear
the obscure pathology of the mimic aneurisms ; but with
this I am not occupied, so I leave them, and go-on to the
last set of tumours that I have to speak of.
It may seem absurd to say that cancerous tumours
can ever be imitated by any nervous disorder ; and,
indeed, they cannot ; yet you will find few cases requiring
a more positive diagnosis than those in which you will
have to assert, as beyond all doubt, that a patient has not
cancer, but neuralgia.
The cases in which the diagnosis is most often neces-
sary are those of suspected cancers of the breast and of
the tongue. Of course any part may be similarly sus-
pected ; but, taking all other parts together, they would
not supply, at least in surgical practice, so large a number
of cases of suspicion as these two.
For the breast, the usual case is that a patient com-
plains of all the pains commonly described as character-
istic of cancer. She has dull, aching pain, it may be, of
the whole or some part of the breast, and often the pain
extends down the arm, more often goes right through to
the scapula; and sometimes it is a darting, lancinating
pain, shooting this way or that, or burning. I think that
you will not find any pain of cancer of the breast which
R
242 NERVOUS MIMICRY.
will not be described by patients with this neuralgic
mimicry of the disease.
But, however severe the pain, and however like what
is supposed to be characteristic, your diagnosis may be
clear. That is not cancer which you cannot feel. Cancer
is a growth, not any kind of pain, and indeed in its early
stages seldom attended with pain ; so that when pain is
strongly marked, and it is very difficult, or impossible, to
feel any tumour or ' lump ' in the breast, you may be
certain that there is no cancer.
In most of these cases the pain has an entirely mental
origin. The patients have been seeing or hearing of
cancer, and their minds have been filled with thoufjhts of
the pain and misery of the disease, till the idea has gene-
rated sensations like those from which it was derived.
I have said ' the mind has been filled ; ' but this is
not necessary. I have known these pains mimicking the
pains of cancer in ])ersons wlio had indeed often thought
of cancers, but never intently, or with any sustained fear.
Just as one may, in dreaming, have vivid impressions of
objects he has rarely, perhaps only once, seen, and scarcely
ever thought of, so may these imitative pains be felt keenly
and often in those who have seldom considered or feared
them.
In these wholly mental cases the confident assertion
of your judgment will commonly suffice for cure. Some-
times, indeed, patients need repetition of the assertion,
especially those who are hysterical. Their trust seems to
die-out after a few weeks or months, and some of them
rather prefer the disease, or the pity to which it would
give them a claim.
CANCER OF THE BREAST. 243
There are cases, however, in which the pain' is not
wholly mental. Neuralgia of the breast sometimes follows
a blow. That which in ordinary persons w^ould be fol-
lowed by aching for some inconsiderable time is apt to be
followed in the nervous by long-abiding pain, which the
mind will invest with all the characters of what it sup-
poses to be the pain of cancer. And, again, neuralgia of
the breast is not rare in gouty or otherwise ' painful '
persons, and most of these are ready to fear that their
pain is due to cancer, and to endow it with the cha-
racters supposed to be distinctive. As fear can give to
any harmless form the shape and substance of that which
it most dreads, and can see spectral terrors in a scare-
crow, so can it give to ordinary neuralgic pains any of
the characters of the pains of cancer. It is especially
prone to do this when the neuralgia is felt in a part
notoriously liable to cancer. In this part fear will
make pain cancerous, even while neuralgic pains, quite as
severe, are common in other parts of the body, and in
them are regarded without dread.
The diagnosis is more difficult when, with the pain
described as like that of cancer, there is, or appears to
be, some change of structure of the breast ; for a very
nervous patient may endow any mammary disease with
any form of pain.
In these cases — which, however, are far more rare
than those of neuralgia without change of structure — you
must make your diagnosis on the characters of the tumour
itself, if there be one. But be cautious about one or two
fallacies. Many neuralgic breasts are a little larger than
their painless fellows. But mere largeness is not tumour,
K 2
244 NERVOUS MIMICRY.
much less cancer. And many mammary glands, whether
neuralgic or not, are rather firmer or tougher in one part
than in others ; and when the tough part is grasped, and,
as it were, doubled between the thumb and fingers, it
may feel something like a hard tumour. Let me advise
you not to use this mode of examining a mammary gland.
I have known it often fallacious, never useful. If you
cannot feel a tumour by feeling or pressing over and
round it, you may believe there is not one ; you may be
certain there is not a hard cancer.
And if you can feel a tumour, do not believe it to be
cancerous merely because it is painful. Judge by what
you can feel, not by what the patient feels ; remembering
always that in the early stages of cancer of the breast, in
which alone there is any difficulty of discerning it by its
tangible characters, it is rarely very painful. All the
popular ideas of the pains of cancer are derived from the
cases of advanced disease, or of cancers growing rapidly
or inflamed or ulcerating. In early cases, and in nearly
all in which the diagnosis is obscure, the greater the pain
the less is the probability of cancer. And, let me add,
neuraluia, even of the severest kind and lonj^est duration,
does not tend to cancer of the breast. I must have seen
more than a hundred cases of neuralgia, and I have seen
only one in which it was followed by cancer, and I have
no belief that in this one the sequence was a consequence. ■
Most of what I have said of the breast might be n
applied, with change of name, to the mimicry of cancer
of tlie tongue. Nervous people hear of the cancer, and
then, witli less or more of tliought about it, have pain and
aching in their own tongues, usually at the side and in
CANCER OF THE TONGUE. 245
that frequent seat of cancer, at the junction of the middle
and posterior thirds. Others have neuralgia of the
tongue ; a dull, heavy, aching on one side of it — a con-
dition which is far from rare in the habitually neuralgic,
especially, I think, in the gouty — and these give to their
neuralgic pains what they believe to be cancerous
characters. And others, with dyspepsia, have sore tips or
edges of their tongues, which they, too, magnify.
It is strange to observe the tenacity with which some
of these patients cling to the most dismal view of their
cases. Though nothing wrong can be seen or felt, and
though months, or even (as I have known) years, may
pass without any disease appearing, yet will they believe
themselves on the brink of misery with cancer of the
tongue. But your diagnosis may be as fixed as their
fears, and had better be more positive. That is , not
cancer which you can neither see nor feel. And do not
be deceived by an unusually large cluster of papillse of
the circumvallate group, or by any little thickening due
to irritation of a tooth, or by a fissure or psoriasis. A
patient's fear will give any of these the sensations of
cancer ; but, as I said of the breast, so here, your diagno-
sis must be founded, not on the patient's sensations, but
on your own.
It is scarcely possible to write usefully on the treat-
ment of a group of diseases such as those to the diagnosis
of which these lectures are devoted. The central fact
in every case, that is, the nervous mimicry dependent on
a nervous constitution, may be constant ; but everything
around it may be, in each case, different. For the
246 NERVOUS MIMICRY.
central condition there is no direct remedy ; for some of
the conditions around it there may be.
In each case it is well to consider that treatment has
to be directed against at least three different things : the
local symptoms, the constitutional condition which may
co-exist or be combined with the nervous, and tlie nervous
constitution itself. Each of the first two may be treated
as it would be in other than nervous patients, provided
the treatment will not do damage to the general condition
of the nervous system.
1. Thus, for pain, general narcotics do more general
harm than local good : they should not be used except
under urgent necessity. A nervous patient who liabitually
or frequently takes any narcotic is usually, I think, past
hope of remedy by anything but long time. Local sooth-
ing means should be always used, and are sometimes very
beneficial, such as frictions with solutions of opium, aconite,
or belladonna, or plasters with belladonna or opium. All
such frictions should be preceded by spongings of the part
with very hot water, so that the skin at the time of friction
may be, as one may say, red-hot. And this hot sponging
is, of itself, often very useful. Indeed, I have known
nothing so good for the painful aching spines which are
common in the mimicries of disease, as that the patient
should sit in tepid water, and have the spine drenched
again and again with water as hot as can be borne, and
then warmly covered and rested. Such drenching with
water wrung from sponges or cloths is better than the
more forcible hot douches : they are apt to shock too
much. Similar uses of hot water and of very hot poultices
^re advisable also for joints and other parts imitating
TREATMENT. '247
pains of real disease ; and I believe it would be hard to
find a case in which cold applications, whether lotions,
douches, icings, or any other, are not mischievous. If
I were to make an exception, it would be, doubtfully, for
the occasional use of the ether-spray-freezing in an in-
tense neuralgic mimicry.
For parts that are nervously, or by erroneous long
rest, stiffened, contracted, or distorted, forcible move-
ments may be used, as I have said in the last lectures,
and in that on bone-setting.^ Besides, speaking generally,
such parts should be regularly exercised, up to any degree
short of that which repeatedly produces exhausting pain
or fatigue, or is not recovered-from after a night's rest.
However little can be done without these or the like
consequences, it should be done, though it be but the
raising of a finger ten times a day. Generally, too, the
use of nervously affected parts should always be for short
periods, and frequent in the day ; and after every time
of exercise there should follow a much longer rest.
And this rule of long rest after exercise should be
observed with the use of frictions, shampooings, douches,
and other like things. Eest should follow them all.
Among other local means of treatment I think I may
certainly say that local bleeding is always useless or worse ;
that severe counter-irritation, or any such as produces
general feverishness, usually does harm, never does real
good ; that light and transient counter-irritation often
seems useful, and may be very often repeated.
Galvanism is, I do not doubt, in many cases useful.
Certainly, it is so in the cases of muscular inaction, whether
1 P. 99.
248 NERVOUS MIMICRY.
the will-less or the power-less. But in the hap-hazard
way in w^hich it is commonly employed it is sometimes
mischievous, and often useless, unless by its mental in-
fluence. Its real value is not likely to be gained without
a much more careful study than is usual.
2. I believe that any other constitutional condition
may co-exist or be combined with the nervous, and may
make not only the diagnosis but the treatment the more
difficult. Whatever treatment is employed must have
respect to each constitution. The scrofulous, the tuber-
culous, the gouty, the rheumatic constitution may need
treatment as much as the nervous. It is through this
great variety of conditions complicating the nervous
disorder that so great variety of treatments are supposed
useful. Many patients are ansemic, and iron does them
good ; some are tuberculous, and some scrofulous, and
these need iodides, or cod-liver oil, or various tonics ;
some have lithic acid diathesis ; some oxalate, and the
remedies that are useful to these may seem mischievous
to others. A single principle of treatment governs what
may be said of all these and other complications : any
error, whether local or general, which complicates the
essential disorder in the nervous system should, if possible,
be remedied ; for every such error is to the nervous
system as an irritant or disturbance augmenting its dis-
order. Under this principle it is that in some of the
cases of nervous mimicry the treatment of some malady
of the uterus has seemed to cure the whole trouble ; and
in some, constant ])urgation ; in some, zinc ; in some,
arsenic or phosphorus. I know that in many cases all
these things are useless. I beheve that when they have
TREATMENT, 249
«
done good, it has been by the cure of something' com-
pUcating the nervous disorder, which being removed
left the nervous system able to recover of itself.
3. Then, lastly, for the treatment of the nervous
system itself. There is no medicinal remedy, nor, I think,
any medicine which can be said to be generally useful.
Iron and zinc and various tonics often seem to do some
good for a time, even in those in whom there is no
evidence of such complication as I just spoke of; but
they do not cure.
That which I think has alwavs to be cared-for is the
full nutrition of the nervous system, by means of right
food, sleep, rest, warmth and other common things of
life.
The food should be ample, nutritious, mixed. JSTo
cases seem to me harder to remedy than those of nervous
patients who say they cannot eat. With many of them
it is only that they cannot will to eat ; with some that
they have so long not willed to eat, that at last the
desire and all sensation of hunger have ceased. But till
they do eat, I believe that nothing will do good.
If there be cases worse than these, they are the cases
of the patients who cannot eat but will drink. Those
who reject all food, and yet drink stimulants often in the
day — stimulants of whatever kind — have no chance of
being cured. They may outlive their malady, but this
is the best that can be hoped for.
As to what may be eaten or drunk, I believe that
very few general rules can be stated. Large quantities
of tea, and of coffee, and of sugar are, I believe, generally
injurious to nervous patients, and much of strong tobacco-
2 so NERVOUS MIMICRY.
smoking ; but for the rest, if any selection of foods needs
to be made, it must be for other errors or defects of health
more than for those of the nervous system.
Sleep and rest should be carefully arranged. As a
rule, I think that nervous patients should sleep at least
eight hours in the twenty-four, and they may sleep one
or more in the day as well as at niglit. But I am
disposed to think that even sleeplessness is less mischievous *
tlian the frequent or habitual use of narcotics. And
whether with or without sleep all exercise should be
followed by long continued rest.
Warmth is always advisable — warmth of air and
clothing and bedding. In some cases very fresh mountain
air seems to have its full invigorating effect ; but I think
these are only among such as can be active ; others must
be kept warm.
But, perhaps, the most important part of the treat-
ment of these cases is the mental part. I have referred
to the infrequency of common-place minds among the
patients with nervous mimicry — some being far above,
some far below, some in various >vays divergent from, the
ideal standard average. It would, probably, always tend
to the remedy of nervous mimicry if the mind could be
brought to an average and uniform level, to a just
medium of common sensibility and common sense. A
few excellent and wise persons might be the worse for
such a change ; but for all except these the change would
be for the better and a chief step towards recovery.
Most of all, the will needs education in these cases.
It needs to be trained to the cure of the mimicry, to the
endurance of pain, to the control of movements, to the
TREATMENT, 251
fixing of the attention on anytlnng rather than the
supposed disease. And very often, in the worse cases,
this training of the will is not possible unless the patient
be separated from the persons and things associated with
the disease. Many patients cannot get well at home.
Some of those about them are too sympathetic ; some too
hard ; some yield too much or too soon : none are
really helpful ; and the patient's will becomes constantly
more feeble, or more widely perverted. In conditions
such as these the patient should hve with quiet sensible
strangers, who can teach the will and exercise and con-
trol it.
The effect of judicious education of the will in the
worst cases of nervous mimicry is sometimes very striking ;
complete recovery is not rare, especially in cases of mimic
loss of power in the spine and limbs, and of mimic diseases
of joints, and mimic gastric disorder and apepsia. Eut
the teacher must be carefully chosen ; for among these
nervous patients are some who are ready to become the
very slaves of persons who have strong wills, or who
profess that they are possessed of knowledge or authority
that cannot or may not safely be resisted. Thus it is that
the worst cases are sometimes cured by the most ignorant
persons, who, by the mere confidence of their assertions,
give confidence and will : but the consequences of such
cures may be as bad as the disease.
252 THE TREATMENT OF CARBUNCLE,
TEE TREATMENT OF CARBUNCLE.
You have recently had the opportunity of seeing four
cases of carbuncle treated in my wards after methods
which you would probably describe, if asked to do so, by
saying that ' nothing was done for them.' Here are the
patients' papers ; and there is, to be sure, no medicine
set-down for them to take, and you know that no surgery
was inflicted on them, — and yet a good deal was done for
them, though the treatment was what does commonly
pass by the name of ' doing nothing.' They were care-
fully fed, washed, cleaned, and bedded ; and their car-
buncles were very skilfully dressed and washed with
proper things ; and every care was taken to shut-out all
untoward influences from them.^ And if any complications
in their cases had arisen, these would have been imme-
diately met. But no complications occurred ; and
therefore, the cases remained without treatment, as it is
said — that is, without medicine, and with no active surgery,
no incisions or anything of tliat kind. And since all
these cases passed through their course very fovourably,
and all the patients were, or will be, discharged at a
comparatively early time after their admission into the
hospital, I will take this occasion of giving you some
observations on tlie manner of treating carbuncle.
* An uniivoidable repetition of part of p. 142.
TACTS IONS. 253
Although you may not have seen much of it, you
must all have heard of the ordinary manner in which
carbuncles were treated formerly, and still are by some ;
a method which consists mainly in making large incisions
through them, and giving large quantities of food and
stimulants, as well as considerable doses of quinine, bark,
and other tonics. I do not at all mean to say that the
things which in these cases I left undone would have
done any harm ; but what I hold of them is, that they
would have been quite useless, and some would have been
sources of great discomfort to the patients. And in the
way in which I speak of these things you may notice that
I exemplify that rule which I have always impressed upon
you, of asking yourselves, w^hen you seem to have been
successful with some medicine, ' What would have hap-
pened if I had not given it ? ' The apparent consequence
of giving a medicine may be plain enough ; but you
cannot too often repeat to yourselves the question — as a
rule, I will not say of practice, but of the study of your
own practice, — 'What would have happened if this or
that, which seems to have been successful, had not been
done ? '
First, with regard to the incisions made in carbuncles.
The ordinary plan, still recommended by some, is, as
soon as a carbuncle is seen, to make two incisions crucially
from border to border. It is said that they must go even
beyond the edges of the carbuncle into the adjacent
healthy textures. I have not followed this method
very often, but I have followed it quite often enough
to be sure that it does not produce the effects which
are commonly assigned to it. It is commonly said that if
254 THE TREATMENT OF CARBUNCLE.
you will thus make crucial incisions into a carbuncle,
you will prevent its spreading. If you can find a car-
buncle two or three days old and cut it right across in
both directions, I think it not unlikely that you will
prevent its spreading. But even therein is a fallacy ; for
there is no sign by Avhich, on looking at a commencing
carbuncle, you can tell whether it will spread or not,
w^hether it will have a diameter of an inch, or of three,
six, or ten inches. The question, therefore, that I spoke
of comes back, ' What would have happened if I had not
made these incisions ? ' And the answer to that question
will be rather according to temper than according to
knowledge. Habitual self-satisfaction will say, 'I saved
that man's life;' self-dissatisfaction, ' I did him no good.'
The true scientific temper stands midway, and says, ' I
will wait for further information on tlie matter — till I
have seen more cases, and then decide whether, in the
earliest stages of carbuncle, incisions are useful or
not.'
After this time of three oi four daj^s I have seen a
sufiicient number of carbuncles tlius divided, and have
divided enough for myself, to say that it will not hinder
the spreading. I liave seen carbuncles spread in as large
a proportion of cases after incisions as in cases that have
not been incised. I liave in my mind a striking case
that occurred to me early in practice, when I followed
the routine, and, in a friend of ]ny own, divided a car-
bimcle most freely. I cut it after the most approved
fashion in de})th and length and width, and then it spread.
After two or three days more all the newly-formed part
was cut as freely as the first, and then it spread again,
INCISIONS 255
and again it was cut as freely. Then it spread again,
and was not cut. Then, in a natural time, it ceased to
spread, and all went-on well. These are only general
irapressions that I give you, because one cannot count
the cases in which cutting has been practised, and those
similar cases in which it has not ; nor even then could it
be said whether those in which the cutting was practised
would have spread if left alone. On a very strong
general impression, however, I say that carbuncles will
spread after cutting in as large a proportion of cases as
they will spread in without cutting.
Then it is said that carbuncles are relieved of their
pain if they are thus very freely cut. Here again,
however, is only a partial truth. A carbuncle of two or
three days' standing, which is hard, tense, and brawny,
is very painful ; and cutting it will relieve, in many cases,
a considerable portion of the pain. But after this, when
the carbuncle begins to soften, and when pustules begin
to form upon its surface, and pus in its interior, it becomes
less painful of its own accord, and without incisions.
Thus there are two distinct stages of carbuncle in reference
to the pain ; the early stage, when it is hard and still
spreading, and is generally intensely painful, and the
later stage, in which that pain nearly or quite ceases. A
carbuncle divided in the first stage, in the first two or
three days of its existence, may be relieved of some of its
])ain ; if divided in the later stage, what little pain may
exist is altogether unaffected by the cutting. And evea
cut as you may, you cannot always cure the extreme pain
that a carbuncle sometimes has, even to its later time.
Some two or three years ago, I was called to a member
256 THE TREATMENT OF CARBUNCLE,
of our profession with a large carbuncle in the middle of
his back. His friends had been much alarmed about the
state of his mind, for he had been suffering great mental
anxiety for some time, and they were in fear lest the
excessive pain of the carbuncle should, in his disturbed
state, do his mind permanent damage. So they persuaded
me to cut it, and I cut it after the old plan, very wide
across, and far into the adjacent textures, as freely as
could be. It did not in the least relieve him. I never
saw a carbuncle through its whole course so painful as
that was, and up to the last, till the healing was nearly
completed, he suffered more or less pain in it. So that
the conclusion in reference to pain must be this : if a
carbuncle can be divided in the first three or four days,
while still hard and brawny, it may be relieved of some
measure of the suffering ; at a later period incisions have
no infhience at all.
The third point is stated thus ; that by the incision of
carbuncles you accelerate their healing, giving facility for
the exit of sloughs. But herein is the greatest fallacy of
all. When the cutting of carbuncles was more customary
in this hospital than it is now, when I did not cut them,
and some of my colleagues did, I used to be able to
compare the progress of cases cut and of cases uncut, and
time after time it was evident that the cases uncut healed
more readily than those cut. A man who is now in the
hos[)ital I have brought round here that I may illustrate
this ])oiiit to you. This is the man, Timothy C , aged
fifty-five. When he came in his carbuncle had a length
of more than six inches, and a breadth of three and a
half; and it formed the ordinary hard, compact, tense.
INCISIONS. 257
and brawny mass that a carbuncle usually does. It had
at that time already begun to suppurate, and little pustules
were pointing on the surface. If I had followed the
practice of incisions, I should have had to make a cut in
one direction of about seven inches, and in the other of
about five, and after that I should have had not onlv the
wounds wide-open and gaping and having themselves to
heal, but a great part of the substance of the carbuncle
fully exposed, and also under the necessity of healing.
But you will observe that the whole of the space tliat now
remains unhealed is a series of openings in the middle of the
carbuncle, through which nearly the whole of the sloughs
have already been discharged, and which now remain
merely like the cavities of little abscesses. In this way
you narrow greatly the extent of wounded surface
to be healed. Indeed, it by no means always follows
that the whole carbuncle, or its whole base, sloughs.
Carbuncles, if not divided, not unfrequently suppurate
only about their centres, and slough only in their central
parts, and the borders clear-up by the softening and
dispersion of the inflammatory products in them. In
every case of this kind you save greatly the amount of
healing Avhich has to be gone through. Nay, in some
cases carbuncles completely abort. One of these cases,
of which I have the paper on the table, was that of a
woman aged sixty-four, who came-in with a carbuncle
nearly as large as this man's in a condition which, it
might be said, required incision at once ; but, with the
exception of two or three small points, no suppuration or
sloughing ensued. The carbuncle dispersed, aborted,
cleared away. This man's case shows the more ordinary
s
258 THE TREATMENT OF CARBUNCLE.
course of events — the sloughing of the central part, the
gradual discharge of the sloughs, and the comparatively
small spaces which are left in the centre of the carbuncle
as the sole spaces in which healing has to be achieved.
On these three points, which are the grounds that
have been assigned as reasons for cutting carbuncles, I
have now given you the evidence on which I have ceased
from the practice. I fully believe that crucial incisions
do not prevent extension ; that there is only a limited set
of cases in which the incisions diminish pain ; and that
with regard to the time that is occupied in liealing with
or without incisions, the healing without incisions is very
clearly and certainly the quicker.
The incisions that I have been speaking of are those
made in the old plan ; crucial incisions. Another method
which I have occasionally tried, but of which I can only
state the same general results, is that of subcutaneous
incision. This has been supposed to liave the same
general effect as the other ; and I think that the same
general conclusions may be drawn respecting it : that it
is a measure unnecessary in the treatment of carbuncle,
and that it retards rather than hastens the healing.
When I speak thiis of the incision of carbuncles,
however, I do not mean to say that there is no condition
of carbuncle in which an incision may be useful.
Sometimes a carbuncle slouglis in its central part, Avitli
one continuous slough of integument holding-in a quantity
of pus. In that case you should cut tlirough the slougli,
or througli any adjacent })art of tlie carbuncle, to let out
the pus, as you would open an ordinary abscess. But
FOOD AND STIMULANTS. 259
this is not a measure whicli is commonly understood by
the ' incision of a carbuncle.'
If you ask why you may not cut a carbuncle though
it may do no good, I reply that you should never be
actively useless, and that there are some cases in which
the cutting does considerable harm. Carbuncles, for the
most part, occiu* in persons broken-down in health,
exhausted by overwork, or by bad food, or in deterio-
rated general health — as sometimes in diabetes or albu-
minuria ; and in all these persons it is a good general
rule to save the blood they need for healing. The loss
of blood from the carbuncle itself would not be con-
siderable ; the hard substance of the carbuncle, when cut
into, does not bleed, or bleeds but little. But to carry
out the incision perfectly, you have to cut into the
adjacent healthy texture ; and this sometimes bleeds very
profusely, so as to lead to all the distress and pain of
plugging the wound with this or that substance to arrest
the blood".
Another measure which is supposed to be necessary
in the treatment of carbuncles, is very high feeding
with large quantities of stimulants. I learned the opposite
of this in one of those cases which you will always do
well to study — those, namely, in which the patient
refuses to do what you advise him. It is from such cases
that we may often learn what is commonly called the
natural history of disease, its course undisturbed by treat-
ment. A gentleman, eighty years of age, had a carbuncle
as big as it could be on the back of his neck ; it extended
from one ear to the other, and from his occipital spine to
3 2
26o THE TREATMENT OF CARBUNCLE.
the lower cervical vertebras. He measured it for his own
amusement, and it was fourteen inches over its surface
transversely, and nine inches vertically — a carbuncle,
then, of the largest size, and one, it might have been
supposed, attended with considerable risk to life. I
urged him very strongly to take a large quantity of what
is called ' support,' for I was at that time under an
impression of its necessity. He absolutely refused, and
nothing^ would induce him to take it. I was therefore
content to stand-by and study the natural history of
disease in this huge carbuncle ; and the natural history
of it was a history that one would have wished to witness
in every carbuncle of its size, for no case could pass
through its course in a better method. He led his
ordinary abstemious life, took moderate quantities of food
and of stimulant, lived through a carbuncle of the greatest
severity, and finally made a complete recovery, and
lived for several years.
Another case which impressed me very much was
that of a friend of my own in the profession, who had a
carbuncle on the back of his neck of very considerable
size. Sir Benjamin Brodie and Mr. Stanley attended him
with me, and under their advice the carbuncle was. cut.
I watched its course afterwards, and felt sure that the
cutting had done neither good nor harm. It went on as
c^arbuncles do when not cut. But the patient was subject
to intense headaches, of which he knew by experience
that the only possible remedy was almost entirely to
leave-ofT food, and absolutely and entirely to leave-off
stimulants. One of these headaches occurred during the
c'ourse of the carbuncle, at a time wJien we had put him
FOOD AND STIMULANTS. 261
upon very fall diet and abundant stimulant. He said
then that he must leave off his stimulants and food, and
we looked with some alarm at what would be the effect
on the progress of the carbuncle. I remember Mr.
Stanley saying to him in his distinct manner, ' My dear
fellow, if you don't take food you'll die.' ' Very well,'
he said, ' then I will die, but I will not take food and in-
crease my headache.' According to his own wish, there-
fore, we reduced his diet to a very low level. The
course of the carbuncle was not affected at all, unless it
were for good ; and after three or four days of this,
which might be called comparative starvation, he de-
scribed himself as being ' as jolly as a sand-boy.'
Since that time I have watched carefully all cases
that I have seen, and I am certain that there is no good
to be obtained by large feeding or abundant stimulants in
ordinary cases of carbuncle. The whole of these cases
that have lately been in the hospital were put on our
ordinary meat diet, with a pint of porter daily ; and I
see that two of them have had four ounces of wine a day,
one of these being a person aged sixty- four and the other
sixty -three, and both having carbuncles of considerable
size. You will find that for patients in private life it will
do very well if you tell them that they may have about
two thirds of their ordinary amount of food, and about
the same proportion of their ordinary quantity of stimu-
lants. But indeed there is scarcely any reason to change
in any material degree the ordinary mode of life of a
patient with carbuncle. So far as he can with comfort
take that to which he is accustomed, so far he may. If
262 THE TREATMENT OF CARBUNCLE.
his diet lias been habitually low, so it may remain ; if
habitually high, so, within certain limits and somewhat
reduced, it may still remain.
Now you may ask what I should set down as the
things to be done for a carbuncle. These boards, nearly
bare as they are, may tell you. In local treatment one
of the best things you can do, if the carbuncle is small, is
to cover it with emplastrum plumbi spread upon leather,
with a hole in the middle through which the pus can
exude and the slough can come away. That, occasion-
ally changed, is all the covering that a small carbuncle
will need. It is difficult thus to cover the whole surface
of a large carbuncle, and to keep it clean ; therefore, I
think that the best application is the common resin-
cerate. This should be spread large enough to cover the
whole carbuncle, and over it should be laid a poultice of
half linseed-meal and half bread. And, if 3^ou want to
exercise your skill, learn to make the poultice well, and
to put it on well, and to keep it in its place well. This
mode of dressing the carbuncle, so far as the materials
are concerned, will last through its whole course ; but
whilst the carbuncle is making progress and discharging
its slough, you will find plenty of room for the exercise
of considerable skill in dressing it, and filling up the
cavities with soft substance spread with this ointment.
J^esides this, the carbuncles are to be carefully washed,
especially with some deodorising substance, as Condy's
fluid, or weak carbolic acid, and the cavities may be sy-
ringed-out with it. The importance of cleanliness is very
great. You noticed in the man wliom I showed you
just now the boils and spots of acne around the edges of
DRESSINGS— AIR. 263
the carbuncle. This points out the necessity of care,
which I suppose had not been taken here, to keep the
surface of the skin adjacent to the carbuncle perfectly
dry, and free from any contact with the discharge, which
seems really to have the power of infecting the neigh-
bouring skin, and so producing the boils which are apt to
arise, sometimes in clusters, around the carbuncle. Of
diet I have already spoken to you. Of medicines I say
nothing. Quinine, bark, and other medicines of the
same class, may be given if you please, or in case of
evident need, and so may aperients ; but there is really
no need of them in an ordinary case of carbuncle. But
there is one medicine which you may find very valuable,
and that is opium, especially in all the earlier painful
stages of carbuncle, in which it relieves the suffering as
thoroughly as incisions or anything I know. After the
early stages, even opium is unnecessary, except for some
patient who may be unable to sleep.
But there is one measure in the treatment of car-
buncle which is seldom employed, yet is of great import-
ance, namely, letting the patient have very free air.
The general idea that carbuncles are very dangerous
diseases has commonly led to the patients being entirely
confined to bed and kept shut- up in their rooms. This is
an unnecessary care ; as I learned from a patient who
refused to comply with injunctions — a patient with a
large carbuncle on the back of his head who would not
keep in his bedroom. He had been accustomed to an
active life, and after seventy or eighty years of that cus-
tom he was quite indisposed to remain in his room. So
with his carbuncle he daily came down stairs, changing
264 THE TREATMENT OF CARBUNCLE.
his room and moving about the house as well as the pain
and weakness would allow him. No carbuncle could go
on better ; all the sta^res were passed through without
any risk or trouble, and it healed with unusual speed.
After that I had a yet more striking case. A lady
came to London ' for the season,' as she called it ; and
she had not been here more than a week or ten days be-
fore a carbuncle came on the back of her head, just
under her hair. It would have been a great vexation to
her to give up all her amusements ; and so, as she did
not mind the pain, she would go out. And it was then
that, for the first time and the last, I saw any value in a
' chignon.' She dressed her carbuncle under her chig-
non, and she went to the parks, to the theatre, and to
dances unharmed, and with her carbuncle quite unseen,
and no trouble whatever followed. It healed after the
ordinary fashion in about the ordinary time. But, in-
deed, you may see cases of this description on a much
larger scale if you watch the carbuncles that come to us
in the out-patients' room. There we often see them of
considerable size, and they do as w^ell among the out-
patients as among the in-patients ; and yet these out-
patients are freely in the air all day, and many of them
continue at their work. So you may set it down as one
point to be attended to in the management of carbuncles
that patients should not be confined to their rooms. They
should at least have change of air in their own houses ;
and, unless they are very weak, they should not avoid
exposure to the fresh open air.
Treating your cases of carbuncle upon this plan, I
believe you will fmd that the great majority will pass
MORTALITY. . 265
through their course well. I cannot tell you what the
ordinary proportion of deaths from carbuncle is ; but I
know that carbuncles are commonly looked-upon in the
profession as dangerous things, and a large carbuncle on
the back of the head is considered to be fraught with
risk to the patient's life. But that is very far from being
the case in my experience. Eemembering, so far as I
can, or rather guessing at the number of carbuncles I
have had to treat, I should say that there is no other
disease of the same extent and general severity which is
attended with so little risk to life. During twenty years
of hospital- and private-practice, T cannot have treated
less than 200 carbuncles ; and of these 200, fom^ have
died, giving a mortality, at a fair guess, of only two per
cent. — a mortality which is less than that of some of the
minor operations of surgery, and really less than that of
any disease of equal severity that you can name. Of
those four deaths, one occurred in a patient aged
seventy-eight, who died of erysipelas after the carbuncle
had nearly healed. Another patient was a gentleman
fifty-five years of age, who died of chronic pysemia. The
third was a gentleman aged fifty, who died with acute
pysemia. And the fourth was a patient of about fifty
years of age, who died rapidly exhausted. The first three
deaths were from causes which may almost be called acci-
dental ; for so w^e call them when occurring after an
operation, and it would be unreasonable to suppose that
any other method of treatment would have averted the
consequences. The other died, possibly, on account of
the deficient stimulation ; for he was a man who had
lived freely, and took during treatment less than he had
266 THE TREATMENT OF CARBUNCLE,
been accustomed to have. The main point, liowever, to
whicli I wish to direct your attention, is that the mor-
tahty may be as little as two per cent. I cannot doubt
that the mortality was considerably larger when car-
buncles were severely cut ; for the severe cutting meant
often severe bleeding, and was attended with all the con-
sequences of large wounds. Thus, though I do not know
the exact proportion, I beheve that the general reputa-
tion of the danger of carbuncle was well founded, and
that among the reasons for the diminished mortality of
carbuncles may be set-down as chief, the more frequent
avoidance of the custom of cuttinsj them.
Speaking of the mortality of carbuncle, however, I
must remind you that I am not speaking of a disease
which sometimes passes under the name of carbuncle —
the carbuncuhir inflammation of the lip which sometimes
occurs in young persons : a disease which you may not
have seen, and may pass many years without seeing. It
was described by a former house-surgeon of this hospital,
Mr. Harvey Ludlow,^ as malignant pustule of the lip.
Dr. Budd, of Bristol, has also so described it. Com-
mencing at one spot, inflammation of the whole lip
f(jllows and spreads to tlie face, and then disease of the
lymphatics ensues, with pyaemia as its consequence. It is
a disease so unlike carbuncle that it ought not to be known
under the same name ; but it seems to me not to agree
with the accounts given of malignant pustule abroad, and
I have seen no other disease like it in England. It
attacks especially young persons from fifteen to twenty-
* TranH. of Abernethinn Society, and ' Med. Times and Oaz.,' Sept. 1852.
See also a valuable paper on this subject by Mr. Thomas Smith, ' Clin. Soc,
Trans./ vol. iii.
MORTALITY. 267
one ; and of fifteen cases that I have seen, only one re-
covered. This disease is not ordinary carbuncle, nor is
its mortality to be counted in estimating the mortality from
carbuncle. Ordinary carbuncle on the lip and face has
none of those special characters, and is not more fatal in
those situations than in any other.
My experience of the treatment of carbuncles in the last
six years, has not led me to deviate from the plan advised in
the foregoing lecture. I have seen a much larger proportion
of fatal cases ; but this is because, since I retired from the
hospital, and as I have grown older, I have more rarely been
consulted for carbuncles not deemed to be dangerous. And
of the seven or eight fatal cases that have occurred, none has
been without serious complication, such as advanced diabetes,
fatty heart, bronchitis or acute pyaemia. So many deaths may
justify a larger estimate of the mortality of carbuncle than the
' fair guess ' which I made in the lecture : but they still leave
it right to say that the mortality of carbuncle not complicated
with serious disease should be less than that of any other
disease of the same extent and general severity.
Later experience has made me nearly sure that the disease
of the lip, mentioned in the last paragraph of the lecture, is
true carbuncle which, because of some peculiarity in the
textures of the lip, especially in young persons, is peculiarly
apt to infect the blood and generate acute pyaemia. The
unlikeness to carbuncle is only in the extremely greater
frequency of pyaemia, and this unlikeness did not exist in a
lad of eighteen, whom I saw with an ordinary carbuncle in the
middle of his back, and in whom acute and rapidly fatal pyaemia
ensued with exactly the same phenomena as I have now so
many as twenty times seen in cases of carbuncle of the lip.
26a SEXUAL HYPOCHONDRIASIS.
SEXUAL HYPOCHONDRIASIS.
The cases which I advise you to inckide under this name
are those of male patients who regard trivial maladies, or
even some of the natural events, iu their sexual organs
with the unreasonable dread or gloom and w^atchfulness
which are characteristic of hypochondriasis. They are
such as are accused or accuse themselves of spermatorrhoea,
or of the other maladies of the sexual organs which
swindling advertisers profess to cure.
You will find that men with healthy nervous systems,
or who are careless, or sensible, or well-infoi'med, will very
rarely consult you on any of the so-called functional
diseases of their sexual organs ; when they have them they
endure tliem witliout harm or distress. Of those who will
consult you, some are merely ignorant of what the
natural actions of these organs are or may be ; some liave
brains too emotional, or spinal marrows too irritable,
hurrying the secretion of seminal iluids and disordering
their emission ; but those are most numerous whose minds,
in reference to tlieir sexual organs, are unsound. The
unsoundness may not be sufficient to be called insanity ;
let it be called hypochondriasis ; and if you will study its
general cliaiacters with the help of the best essays on the
IGNORANCE OF SEXUAL THINGS. 269
subject, and best of all with the essay on Hypochondriasis
by Sir William Gull and Dr. Anstie in Eeynolds's System
of Medicine, T may limit myself to speaking of the con-
ditions of the sexual organs which are associated with
disorders of the nervous system.
Of these I will speak rather fully ; but first, let me ask
you to note the ignorance concerning sexual matters of
which I just now spoke : for it is the source of a kind of
hypochondriasis in some who, in mere ignorance, imagme
miseries for themselves or are njade miserable by others'
falsehoods.
Ignorance about sexual affairs seems to be a notable
characteristic of the more civilised part of the human race.
Brutes, even those most changed by our domestication,
copulate as naturally as they eat or defa3cate. As the
instinct for food leads them to eat, and carries with it all
the knowledge necessary for the choice and taking of
their food, so the sexual instinct has with it the knowleds^e
how to copulate. It is the same, I believe, witli the
least civilised of our race ; but it is not so with the most
civilised. It seems as if, in the course of generations, the
transmission of intellectual powers gained by education
had the effect of subduing or superseding those of instinct.
How far up the grades of civilisation this change begins,
I do not know ; but among ourselves it is certain that the
metliod of copulating needs to be taught, and that they
to whom it is not taught remain quite ignorant about it ;
as ignorant as, I suppose, we shoidd be of wliat to eat
and drink if we were not taught. Of course very few,
I mean very few of our sex, grow-up witliout being
tauglit, either by the talk of schoolfellows or by books or
270 SEXUAL HYPOCHONDRIASIS,
Other means ; but a few grow-up and even marry in
complete ignorance ; and this ignorance, which is rare
among men, is very common among well-educated
w^omen.
The fact is of much interest in relation both to the
natural history of our race, and to the frequency of
sexual disorders dependent on the mind or on the nervous
system. For sexual desire arises and grows without the
knowledge how to satisfy it ; and in the learning how to
satisfy it errors and fancies and things half understood
get into the mind, and become to some men sources of
misery and fright, and to some the subjects of hypochon-
driac gloom and watchfulness.
Among the merely ignorant you will find that, if they
be otherwise sensible people, they need only to be told
the truth concerning the disorders, real or imaginary, for
which they consult you. Knowledge will cure them.
But if they be or have become hypochondriac they will
not receive, or will not retain, knowledge ; their er-
roneous beliefs will be to their minds stronger than your
truths.
Of these I shall have to speak again in reference to
all the sexual disturbances of which they "complain.
Now the complaint of some is that semen passes with
their in^ne, and that all their ' strength is going from
them;' and of this they give various symptoms, which,
if they be at all true are due to something else. For the
general notion of semen passing witli the urine is erroneous
and is usually derived from dishonest advertisers, who
make it one of the grounds on which they rob their
patients.
SEMEN IN URINE. 271
There is, indeed, a very rare case in which after
gonorrhoea or other disease affecting a seminal vesicle, a
part of it seems to become sacculated, and may be so
filled that mucus, and perhaps seminal fluid, may be
pressed from it in the last lifting efforts of the muscles
for expelling urine. And this out-pressing may be attend-
ed with sensations of discomfort, shuddering and tremors;
but it is harmless. In the ordinary cases, and those of
hypochondriasis, the supposed semen is mucus from the
bladder which, when it exists in its natural small quantity
in the urine, appears as a pale dim cloud at the bottom
of the vessel, sometimes sparkling a little when light
passes through it.
As to semen passing with the urine, I am nearly
certain that it never does so unless when an emission of
semen, in whatever way provoked, has lately taken place
or where there has been disease of a seminal vesicle. In
the former case some semen, remaining on the walls of the
urethra or possibly having passed into the bladder, is
washed-out with the next stream of urine, and may be
found in it with the microscope. I once examined, for
many days in succession, the urine of a patient who was
persuaded that he passed semen with it ; and semen could
always be found when he had had a nocturnal emission,
but never on any other occasion. A former colleague of
mine assured me that he had frequently observed the
same thing after copulation. And this, I believe, is the
whole truth concerning semen passing with urine ; what-
ever may chance to be left in the urethra after an emission
is washed-out. But that which frightens the ignorant
and the hypochondriacal is not even this ; it is mucus of
272 SEXUAL HYPOCHONDRIASIS.
the urinary passages, eitlier quite healthy or in some
trivial manner chancred. Tliis form of what is called
spermatorrhoea, therefore, sliould be treated by instruction,
wliich the merely ignorant will receive, and the hypochon-
driacal, very probably, will not.
Xot much unlike this misunderstanding about vesical
mucus is anotlier in which some people, cliiefly middle-
aged and elderly with diminishing sexual powers, make
themselves miserable. They find in their urine little
flakes or threads of floating mucus, which, they say, are
always washed out of the urethra at the beginning of the
urine-stream, especially in the morning. Tliey watch
these with the greatest anxiety ; and send them to you
on bits of paper or of glass, begging you to examine them
very carefull5^ I believe that they are bits of prostatic
mucus, secreted in the night and washed-out with the
morning-urine. But, whatever they may be, they are not of
the least importance. You may find them passed by men
who neither know nor care anything about them and
whom they never harm ; and even hypochondriacs go on,
month after month, passing them and yet suffering nothing
but their mental misery.
There is really nothing more serious in these flakes of
mucus, than there is in the mucus for which some men,
or even these same men, blow their noses oftener tlian
others ; or in the secretion which makes some people's
eyelids stick togetlier in the morning. It seems strange
that mucus from one ])lace should make peoi)le so much
unhappier than mucus from another. But this is tlie
usual character of hy[)Ochondriasis ; it is as if a moibid
URETHRAL MUCUS. 273
element of the mind could localise itself, as a morbid
element of the blood may, in some ' place of election.' ^
Again, some or the same persons are unhappy because,
as they say, they pass semen during defaacation. But
these, again, do nothing more than healthy men often do.
When the rectum is emptied Avith much muscular force,
and especially when large solid fgeces are being passed
the contents of the vesiculge seminales and of the prostatic
ducts, and, I dare say, of Cowper's and other mucous
glands besides, are apt to be pressed-out ; and hence it is
not rare for healthy men to find mucus, or some fluid like
it, escaping from the urethra during defeecation attended
with straining. And, when the vesiculas seminales are
filled with semen, as they may be when it is long since
an emission took place, or when, in an emission they are
not emptied, their fluid together with semen may be
pressed from the urethra with something even of the
sensation of emission. All these things happen to healthy
people without harm : they are not unnatural ; certainly
they are not effects or signs of disease : and when anyone
comes to you complaining of them, it is his mind, not his
sexual organs, that requires treatment.
Another subject of gloom and alarm to some is that,
during sexual excitement, and, as they suppose, worse
still, when they wake in the morning, they find a clear
colourless fluid flowing from the urethra or easily pressed
from it. Here, again, the complaint is of that which is
* Prostatorrhoea, prostatic gleet, or whatever else the disease may be
called which is attended with constant excessive secretion from the prostate,
or vesiculai, or both, is not liere referred to. This is a real disease and very
troublesome, whether associated or not with spinal irritation or with hypo-
chondriasis.
T
274 SEXUAL HYPOCHONDRIASIS.
natural, and it would be quite as just if directed against
tears during grief. The urethra natiu-ally secretes mucus
during sexual excitement ; it secretes more or less in
different persons, but some, I believe, in all ; and as for
the morning-secretion, it is due either to some sexual
excitement during sleep, forgotten before waking, or to
the general condition of turgescence or erection of the
sexual organs which, in most healthy persons, exists
during sleep or some part of it. In no case is this
clear urethral mucus a sign or, consequence of disease,
unless indeed when an excess of it is a residue of
gonorrhoea. It is, I think, most abundant and most
quickly formed in those whose sexual organs are more
irritable than potent ; but this is the worst that can be
said of it ; and even in these it is not the sexual organs,
but some part of the nervous system, the brain or the
spinal marrow, that is in the wrong. In no case does
the secretion deserve to be called or treated as a disease.
Again, there are some to whom, whether through
ignorance, or misguidance, or liypochondriasis, a varicocele
is a source of misery and dismay. They look on it as a
fore-runner of impotence, and of wasting testicles, and I
know not what besides. All such fears are groundless.
Varicocele is troublesome because of the sense of weiirht
and aching which sometimes, tliougli far from always,
attends it, and whicli is sometimes much increased by
long standing or walking. In some cases, too, the dilated
veins, like varicose veins in the leg, are apt to become
inflamed or very sensitive. But this, I beheve, is the
widest limit of the harm that varicocele ever does. I do
not believe that it ever produced wasting of a testicle or
VARICOCELE, 275
impotence or any such thing. It is common enough to
find varicocele in quite healthy men who, being sufficiently
careless or sensible to make light of it, suffer no harm
either mental or bodily. Some who have it while they
are single and chaste are cured by marriage ; and in some
it ceases to cause even its slight occasional aching when
they begin to grow old. In short, the cases in which
varicocele is more than a trivial affair are very few ; and
in these few its mischiefs are not such as the sexual
hypochondriacs imagine. They are, indeed, altogether
distinct from the functions of the sexual organs ; being
such achings and wearing pains as may be felt in varicose
veins in the legs. These may be sufficient to disqualify a
man for military service ; but they are not sexually
important ; and, in those who believe they are, it is a
mental error, not a bodily one, that needs cure.
I can very positively give you the same assurance
about those who will consult you on several other things ;
such as the scrotum being too pendulous, or the penis
being cold or shrivelled, or the testicles too small when
in fact they are of ordinary size.
But now I must speak of something which may, in its
greater degrees, have the character of real if not serious
disease ; I mean the nocturnal and other involuntary emis-
sions of semen. I say, in its greater degrees ; for, in the
lesser, the emissions are natural, and it is a sign of igno-
rance or hypochondriasis if the mind dwells sadly on
them. And, I may add that of all the cases of such
emissions on which you will be consulted, not more than
one in fifty will deserve serious consideration unless for
the state of the patient's mind and nervous system.
t2
?76 SEXUAL HYPOCHONDRIASIS.
To those who lead chaste hves, and to some of those
Avho do not, nocturnal emissions of semen are natural
occurrences. I never met with a chaste healthy man, of
whom I had occasion to ask about them, wdio did not
say that he had them sometimes. Their frequency is
in different men very various : varying according to
many things, such as climate, diet, social habits, and,
above all, I think, accordins^ to the deixree in which the
minds of those who do not have sexual intercourse are
directed to sexual matters. Thus nocturnal emissions
may vary from once or twice in a week, to once in two
or three months, or, at times of unusual exhaustion or
excitement, they may exceed those rates or may fall short
of them : but in both sets of cases and in all the inter-
mediate frequencies they are consistent with good health.
Men who are careless, or sufficiently well-informed, say
nothing about them, and suffer no harm. When, there-
fore, any person with a sound nervous system, and having
nocturnal emissions within such limits as I have men-
tioned, consults you about them, it is best to tell him
tliat they are natural occurrences wdiidi may be left to
their own course, and you may add tliat they cannot be
put an end to and ought not to be if they could.
But the case is different in men with over-sensitive
nervous systems, or in whom one may believe that at
least that part of the s])inal marrow which is in nearest
relation with tlie sexual organs is over-irritable. In this
condition tlie emission of semen is apt to take place
with mucli less than tlie normal amount of excitement.
Hence it may take place too quickly during or even be-
f(jre sexual intercourse ; sometimes without erection and
SEMINAL EMISSIONS, 277
almost without sensation ; sometimes from the mere
friction of the dress in riding or walking, or during sen-
sual thoughts ; and frequently at night with or without
sensual dreams. This if anything might be called sper-
matorrhoea ; but even this is not properly a disease of the
sexual organs, it is a disease or a disorder of the nervous
system, and may most probably be referred, as I have
said, to a too irritable condition of the spinal marrow or
of some portion of it. For, with the too frequent and
too quick emissions there are always other signs of
nervous disorder which, though commonly regarded as
due to the emissions, are really not so.
The chief of these sims are achino^ of the back and
lower limbs, especially after emissions ; readiness to be
fatigued, and in all fatigue pain ; weary limbs and spines ;
indisposition or seeming incapacity for mental exercise ;
defect of will and of power of attention-, often restless-
ness at night and unrefreshing sleep ; hysteric fits or feel-
ings. Many patients, too, are troubled with palpitation ;
many with constipation ; some with excess of lithates ;
some with oxalates in their urine ; not a few with irri-
table bladder ; some with various nervous indigestions ;
some with coldness of feet and hands.
Now, neither these nor any other of the signs com-
monly enumerated with them are characteristic of disease
of sexual organs : they are signs of a central nervous dis-
order ; they are the very same as are found in many
cases of ' spinal irritation ' and of so-called hysteria in
which there is no indication of any sexual disturbance,
but, if anything, some disturbance at the heart, or the
bladder, or a joint or some other part. Moreover, these
-/"
SEXUAL HYPOCHONDRIASIS.
nervous signs bear no proportion to the emissions, and,
thol-igh common!}^ aggravated by them, are only so aggra-
vated as the same symptoms are in nervous women at the
menstrual period, or by any other sudden or consider-
able expenditure of nervous power. ^
The utter prostration which women, and some men
too, with spinal irritation complain of after walking is the
counterpart of that which is complained of by these
nervous patients after their emissions ; and I have heard
patients complain of it even during digestion, or after
their daily defalcations, though these were with neither
pain nor straining. It is true that there are few if any of
these cases worse than those in which the nervous dis-
order, which I hold to be the primary affection, is directed
on the sexual organs, or has been wilfully directed
on them by frequent masturbation or irregular sexual
practices ; but, in not a few of those who lay the fault of
their nervous troubles on their seminal emissions, the
sexual organs act healthily. One of the worst cases that
I have ever seen was in a married man wlio, because of
back-ache and many more of the sensations I have enume-
rated, lay, hke many hysterical women, constantly on his
back, travelled on his couch, or at most moved slowly on
crutches. He liad occasional sexual intercourse; and his
back was always more painful after it, and he felt
miserable and exliausted and prostrate ; but so lie did
after a walk or any other unusual expenditure of nerve-
^ This lecture wns iriven before those on Nervous Mimicr}'; but tlie
points of likeness between the subjects of sexual hypochondriasis and those
with disorderly nervous systems to whom those lectures relate are very
numerous and clear. Espocially, there is likeness l)etween the men with
this disease and the women who have uterine disturbance : and the dif-
ference in their mental states agrees with the general fact that hypo-
chondriasis is much commoner in men than in women.
SEMINAL EMISSIONS. 279
force. In another, a man of 30, who lay helpless and will-
less, weak-eyed and utterly enfeebled, a very type of the
supposed victims of spermatorrhoea, nocturnal emissions
occurred very rarely. They were followed by increase of
back-ache and other miseries, but in no greater degree
than was every unusual mental or bodily effort : and this
patient had never had sexual intercourse, had masturbated
only twice or three times in his life, and had had very
few nocturnal emissions.
Now, in some of these cases of rapid and frequent
emissions, the consequence, as I want you to believe,
and not the cause, of nervous disorder, there is no mental
error; the patients are not more than reasonably dis-
tressed by the inconvenience they suffer. But in many
cases, hypochondriasis is associated with the rest of the
disorder, and increases immeasurably both the misery and
the difficulty of cure. The patients are full of apprehen-
sions, unable to divert their minds from their sexual
functions, constantly watchful of their sensations and
making them constantly more intense. And further
mischief follows all this : for the direction of the mind to
the sexual organs makes both them and the parts of the
nervous system associated with them more and more
irritable ; it increases the secretion of seminal fluid and
hurries its discharge. The mind thus continually multi-
plies the sources of its own misery.
Few conditions are more pitiable than those of
hypochondriacs who thus suffer, and few more difficult to
cure. Your chance of doing good will depend mainly
on the skill with which you can influence the patient's
mind: for of the components of his case the mental
28o SEXUAL HYPOCHONDRIASIS.
condition is the worst, the irritable spinal marrow the
next, the state of the sexual organs the last, in order of
gravity. JSTot that local treatment is to be neglected, for
if the unnatural sensibility of the sexual organs can be
diminished the mind may be less often distressed by
emissions.
To this end, cold enemata are sometimes useful, and
sometimes galvanism ; and in some cases the passing of
bougies or catheters, witli or without caustic for the
prostatic part of the urethra. But all these things often
fail ; and, as for the last, I have seen so many cases in
which it has been mischievous that I am sure it should
be used seldom and never without more than ordinary
skill. But of its being sometimes useful under these
conditions I cannot doubt.
For the nervous state you must use, as for any other
cases of ' spinal irritation ' iron, good food, and good air,
and the correctives of any coincident disorder of the
digestive or other organs ; and you must persuade to a
robust, sensible and fully occupied habit of life, with
much sleep and the best self-control that can be obtained.
But do what you may the hypochondriasis will, in the
worst cases, remain ; and if, even, the sexual trouble
should cease, the mental wrong will continue, only
changing its subject, or dwelling on the past as gloomily
as it used to dwell on wliat was present. And in some
the hypochondriasis will gradually drift into a more
evident insanity.
Now, when one of tlicse patients becomes insane the
blame is commonly laid on his sexual organs, or on his
having practised masturbation. Before I end, I will tell
IMPOTENCE, 28r
you the wrong of this : but I must first speak of another
of the conditions on which hypochondriacs think erro-
neously ; namely, impotence. This impotence, or even
greatly reduced sexual power, is so distressing even to
those who may be called reasonable men that you may
sometimes be ready to ascribe to mental disorder what is
a material disease or defect. Your study, therefore, in
each case, must be to ascertain whether the impotence
complete or incomplete be real, or due to ignorance or
some nervous disorder ; or whether there be no impotence
at all but only an hypochondriacal fear or false persuasion
of it. Now of the real cases of impotence I can only
enumerate the chief forms. It may be due to disease or
wasting of the testicles, but this, unless the disease or
wasting be extreme, is very rare. (Observe, I do not
speak of sterility which means only inability to beget
children, but of impotence w^hich means inability to
copulate.) It may follow abscess or other acute disease
of the prostate. Very rarely and inexplicably, it is
sometimes a sequence of fever ; sometimes of injuries of
the brain or spinal cord. It is found duiing exhaustion
from excessive and anxious mental work, with 'jaded
brains ; ' and during some forms of dyspepsia, with oxa-
luria : but in these cases it is only temporary. It is not
rare with advanced diabetes ; and is common with several
forms of degeneracy of the spinal cord. In old age it
is happily not rare. At any age it may begin and
continue very long in those who have been excessive in
either sexual intercourse or masturbation. Nay, all sexual
power and desire may cease in apparently healthy men,
and without apparent cause, at unusually early ages : in
282 SEXUAL HYPOCHONDRIASIS.
cases that I have known, as early as thirty-five or forty
even in those who never masturbated and very rarely had
sexual intercourse.
But although the physical causes of impotence and
great decrease of sexual power may be thus numerous,
yet from all these causes together the cases are less
frequent than those due to nervous disorder or to mental
defects ; and the impotence which is complained of or
dreaded without any real reason is more common still.
The mental and nervous defects which may make a
man impotent are various in different persons ; some
hindering or interrupting erection ; some preventing
emission ; and they are as various in degree ; some are
only occasional, a few are habitual or scarcely constant.
They may be cured, if at all, by means addressed to the
mind or to the nervous system ; but they are all hard to
cure ; as hard as it is to cure stammering, whether in
speech or any other function, or to cure any of the dis-
orders of those functions for the perfection of which the
will must act in exact harmony with parts not under its
direct control.
I have enumerated all these causes of impotence to
help you to guard against the risk of treating as a mere
hypocliondriac any one who really has this malady from
either mental or physical causes. As a rule the distinc-
tion is not difficult. They who complain of impotence
alone arc distressed about it, and very anxious for its
cure ; more so than to the cool judgment of anybody else
may seem reasonable ; but here is the boundary of their
unhappiness ; they do not tell or prophesy other
miseries, and do not give up their minds to their diseases.
IMPOTENCE. 283
Moreover, they who are impotent, or nearly so, from
other than mental or nervous states have a loss of sexual
desire as well as of power.
The sexual hypochondriac may or may not be
mentally impotent ; but in the great majority of cases is
not. Most of those who consult you will tell you that
though they have sexual desire yet are impotent, or
are afraid they are, and are therefore afraid, to marry,
because they have some of the trivial things I have
been speaking of ; occasional nocturnal emissions, or
urethral mucus or varicocele or something not more im-
portant. Now if a man has sexual organs, including the
prostate, not manifestly diseased or wasted, and has erec-
tions and occasional nocturnal emissions, and any sexual
desire, you may be sure that he is not impotent unless
he has very clear facts to prove that he is. The state-
ments that hypochondriacs make to show that they are, or
are becoming, impotent are usually evidences that they
are not. And what is true of hypochondriacs is equally
true of those who are frightened by mere ignorance of
sexual matters, or who have been fraudulently misin-
formed.
You may observe that, in speaking of sexual hypo-
chondriasis, T have spoken of three different classes of
men or boys in whom functional disorders of the sexual
organs may need to be treated. There are, first, the
merely ignorant or misinformed ; next, those with over-
sensitive or too irritable nervous systems ; and lastly, the
hypochondriacs. The conditions respectively charac-
teristic of each may be mingled in various degrees, but
they are worth keeping in mind as guides to treatment.
284 SEXUAL HYPOCHOKWRIASIS.
The patients of the second class alone need medicinal
help, and what this may be I said just now : the others
must be mentally helped.
With careful and very positive teaching you will
cure the io-norant, and do cfood to all but those whose
hypochondriasis is near to complete insanity. But on
some subjects of your teaching you will have to be very
clear as to matters of fact ; especially, for instance, as to
the practice of masturbation, to which many of your
patients will ascribe their chief distresses.
JSTow, I believe you may teach positively that mastur-
bation does neither more nor less liarm than sexual inter-
. course practised w^th the same frequency in the same
conditions of general health and age and circumstance.
Practised frequently by the very young, that is, at any time
before or at the beginning of puberty, masturbation is very
likely to produce exhaustion, effeminacy, over-sensitiveness
and nervousness ; just as equally frequent copulation at the
same age would probably produce them. Or, practised
' every day, or many times in one day, at any age, either
masturbation or copulation is likely to produce similar
mischiefs or greater. And the mischiefs are especially
likely or nearly sure to hap])en, and to be greatest,
if the excesses are practised by those who, by inheri-
tance or ciicumstances, are liable to aii}^ nervous
disease, — to ' spinal irritation,' epilepsy, insanity, or any
other. r>ut tlie mischiefs are due to the quantity, not to
the method, of the excesses ; and tlie quantity is to be
estimated in lelation to age and the power of the ner-
vous system. I have seen as numerous and as great evils
consequent on excessive sexual intercourse as on ex-
DREAMS. 285
cessive masturbation : but I have not seen or heard
anything to make me believe that occasional masturba-
tion has any other effects on one who practises it than
has occasional sexual intercourse, nor anything justifying
the dread with which sexual h3^pochondriacs regard the
having occasionally practised it. I wish that I could say
something worse of so nasty a practice ; an uncleanliness,
a filthiness forbidden by God, an unmanliness despised
by men.
Another point on which you may have to teach is
that of dreams associated with nocturnal seminal emis-
sions. Men of scrupulous conscience are deeply dis-
tressed with the thought that these emissions are due to
sexual feelings which they ought to be able to suppress
even in their dreams ; they look on them as tokens of a
prevalent impurity of mind w^hich they must cure. Well,
you may tell them that, according to all we know of
dreams, it is not the dream that excites the emission, but
the natural and involuntary erection and emission that
determine the dream, and that over the erection and
emission that may occur in sleep or on just waking it is
nnpossible that any man should exercise direct control ;
he might as well try to control while asleep the tone of
his snoring or the posture of his limbs. Some indirect
control a man may have on all these things, and on the
sexual part of them it may be held that the more the
mind while awake is occupied in other than sexual
matters, and so occupied that it is not even necessary to
use any effort for the suppression or exclusion of sexual
thoughts, the less will be the secretion of semen and the
sensibility of the sexual organs, and therefore the less
286 SEXUAL HYPOCHONDRIASIS.
frequent the excitements and emissions during sleep.
But, in some persons, and, as I believe, in the great
majority of those who are chaste, nocturnal emissions and
the associated unclean dreams are simply irrepressible :
they are due to a natural secretion of semen which we
have no means of suppressing and no right to suppress.
Therefore, to men with healthy nervous systems you
must tell that their nocturnal emissions are evidences of
health rather than of disease. And to those in whom too
frequent emissions are connected with a too irritable state
of the spinal marrow, you may tell that they cannot and
ought not to be wholly suppressed ; but that they may
be remedied by marriage, and may, very probably, be
diminished by means that wnll improve the condition of
the spinal marrow.
To all alike you may try to teach a judicious care-
lessness about these things : a state of mind which would
be an inestimable blessing to many besides these sexual
hypochondriacs.
Many of your patients will ask you about sexual in-
tercourse and some will expect you to prescribe fornica-
tion. I would just as soon prescribe theft or lying or
anything else that GoD has forbidden. If men will practise
fornication or uncleanness it must be of their own choice
and on their sole responsibility. We are not to advise
that which is morally wrong, even if we have some reason
to tlnnk that a patient's health woukl be better for the
wrong-doing. But in the cases before us, and I can
imagine none in wliich I should think differently, there is
not ground enough for so nuich as raising a question
about wrong-doing. Chastity does no harm to mind or
MENTAL TREATMENT. 287
body ; its discipline is excellent : marriage can be safely
waited for ; and among the many nervous and hypochon-
driacal patients who have talked to me about fornication,
I have never heard one say that he was better or happier
after it ; several have said that they were worse : and
many, having failed, have been made much worse. ^
The mental treatment which I have thus suggested
will be in many cases sufficient. It will be more or less
useful according to the degree of good sense possessed by
the patient. A sensible man, who has been only ignorant
on sexual subjects, who can understand evidence and is
ready to believe those who are most likely to tell him
what is true, will be cured when the truth is told. At
the opposite extreme, the worst of the hypochondriacs will
be almost incapable of cure : they will believe nothing
hopeful ; they will be dull to all common-sense statements ;
many of them will prefer to be guided by rogues rather
tlian by honest men.
Between these extremes you will have various degrees
of success ; and in the vast majority of cases time does
good. Some few patients, whose hypochondriasis is a
form of inherited insanity, become plainly insane ; some,
though they marry and have duly regulated sexual inter-
course, and may cease to have involuntary emissions, yet
retain their other nervous symptoms, and continue hypo-
chondriacal ; but the vast majority get well. Some fall in
love, marry, and are cured ; some getting into the
^ Professor Humphry very justly points-out that the functions of the
sexual organs, and we may include with them the related parts of the
nervous system, 'may be suspended for a long period, possibly for life 5 and
yet they may be sound and capable of being roused into activity.' The
same can scarcely be said of any other parts. Holmes's System of Surgery,
vol. V. p. 151.
288 SEXUAL HYPOCHONDRIASIS.
weighty responsibilities of life, have things to think-about
more important than their sexual organs, and in all,
as they grow older, the spinal marrow becomes less
irritable, so that the emissions, if they have been annoyed
with them, become less frequent and are attended with
less feeling of exhaustion.
Now, let me end by speaking, as I said I would, about
the statements that miseries beyond any that I have told
of are frequent consequences of the so-called functional
sexual diseases. Epilepsy, all forms of paralysis, wasting
palsies, amaurosis, impotence, insanity, idiotcy, emacia-
tion, disease of the heart, phthisis, and whatever else may
frighten the timid, or attract the morbid fear of the
hypochondriac, are advertised by swindlers as the sure
consequences of sexual disorders, unless they be averted
by some secret treatment. And these men live on tlie
insane and the foolish whom they can attract. They
would do less harm, and be less encouraged in their
frauds, if they could not refer to the works of some
members of our own profession for opinions justifying
what they pretend to be their own.
First among these false teachers is Lallemand. His
picture of Spermatorrhoea, in its complete form, is a
description of something which I believe to be unknown
among Englislimen. It may be tliat there is no such
disease in France : a wild imagination may have suggested
it : but whether it can be found in France or not, 1
believe you will never see it here. I have not yet seen
such a case as any of tlie worse cases wliicli Lallemand
describes, nor any which would justify the general tone
of his descriptions. To many others with as good oppor-
INSANITY. ' 289
tunities as myself for seeing rare and severe cases they
are as completely unknown : and I observe that English
writers on the subject, when they wish to tell the worst
things to which spermatorrhoea can be said to lead, speak,
not from their own observations, but from what they
believe to have been Lallemand's.
But setting-aside his account, you will find, even
among honest English writers, more serious troubles
assigned to sexual disorders than I think they can justly
be charged with.
In speaking of the symptoms of irritable spinal marrow
associated with frequent seminal emissions, I indicated
the fallacy of the argument on which it is held that these
symptoTns are the consequence of the emissions. The
emissions I said and (I hope) showed, are the conse-
quences not the cause of the disorders of the nervous
system ; they may aggravate the condition from which
themselves arise, but it is only in this sense that any
measure of the disease can be ascribed to them.
Nearly the same may be said concerning the other
supposed consequences of sexual disorder and sexual
excess of whatever kind. Let us take, for instance,
insanity ; and what is said of it might be said of epilepsy
and the other horrors assigned as consequences of sper-
matorrhoea and masturbation.
Masturbation and sexual excesses are commonly as-
signed as the cause of insanity in a considerable propor-
tion of the msane inmates of asylums. But, I think you
will find that no estimate is attempted of the probability
that they who are said to have been thus made insane
would have become insane without this or any other
u
29Q SEXUAL HYPOCHONDRIASIS.
excess. No doubt, in any man who inherits a disposition
to insanity, excess of any kind, whether in sexual things,
or in drinking, gambUng, or any other, will hasten or
determine the advent of insanity : but excesses do not
make men insane who have naturally healthy brains.
Think of the number of habitual drunkards whom we see
d}dng here : th-e poor wretches are not mad, unless their
drunkenness be a sign of it, an effect not a cause of in-
sanity. Or, think of the number of sensualists in all
classes of society, who, to the last degree and their latest
life, stimulate and indulge their sexual desires in any way
they can. These do not become insane in any larger
proportion than do gamblers, or over-active politicians,
or even the vehement students of science. To determine
the influence of excesses in producing insanity you must
count not only the insane but the sane who have com-
mitted excesses and retained their mental power.
And, even among the insane there are many of whom
it would be truer to say that they masturbated because
they were insane, tlian that they became insane because
they masturbated. It is tlie same as with drunkenness.
Habitual and paroxysmal drunkenness seem to me more
frequently the consequence of insanity than insanity is of
them. Certainly, the most marked cases are in those
who are members of families in which insanity and
other maladies of nervous centres are prevalent, and in
tliose who arc on other and previous grounds known to
be not wholly sane or of average mind. Given a predis-
position to insanity, and, no doul)t, any of these exciting
or, as tliey may better be called, exhausting causes may
induce it ; may hasten it or determine its occurrence.
INSANITY, 291
And the greater the disposition, the less need be the ex-
haustion that will suffice : while in those in whom there
is only the least, if any, disposition to insanity, nothing
less than the utterest exhaustion from excess may suffice
to produce it, if even this may. The drunkards and
sensualists who live and die sane are too many to let us
speak of hard drink, or masturbation, or sexual excesses
as causes of insanity, unless under many reserves and
conditions.
And what is true in respect of insanity is true in respect
of other assigned consequences of sexual disorders.
These disorders are effectual exciting causes of only such
diseases as the patients are prone to ; and the proneness
or predisposition is much nearer to the essence of the
disease than is the exciting cause.
tj 2
292 GOUTY PHLEBITIS.
GOUTY PHLEBITIS.
I HAVE met with certain cases of phlebitis, tlie hke of
which I cannot find on record. I propose, therefore, to
give some account of them. They are all examples of
the so-called adhesive phlebitis ; the disease in which in-
flammation of the coats of a vein is associated with clot-
ting of blood in its canal, but not with suppuration or
pysemia. Of many of them, indeed, I cannot tell, any
more than of certain other forms of phlebitis, whether the
inflammation or the clotting were the first event, nor,
therefore, whether they are to be referred more properly
to phlebitis or to thrombosis. But I give the former
name to them all because it is in most common use
amongst us ; and is probably correct for at least one part
or stage of every case.
Many of the varieties of adhesive phlebitis have been
so well described, that I need only refer to them for the
sake of comparison.^ Such are —
^ Such doscriptions may bo found in, or by means of, Callender, Art.
^Pysemia;' Holmes's Syst. of Surj^^ery, vol. i., and 'Diseases of Veins/ in
the same, vol. iii. ; S. Weber, Ilaudbuch der Chirurgie, von v. Pitha ii.
IVillroth, R iii. Abth. ; llumpliry, 'On the Coag-ulation of the Blood in
the Venous System during Ijife, lH/>{); ' Mackenzie, Patlu)l. and Treat-
ment of Phlegmasia Dolens, 18()2 ; Henry Lee, Diseases of the Veins, 186(5;
Virchow, C(!llular Pathology; by Chance, lect. x. 18G0; Kokitanj^liy,
Pathologische Anatomie, P. iii.
GOUTY PHLEBITIS. 295
1. The traumatic; including those due to distension.
2. Those occurring in exhaustion during, or after,
either acute or chronic disease.
3. Those due to extension of inflammation or of
blood- clotting from ulcers, morbid growths, or
gangrenous or acutely inflamed parts.
4. Those of the so-called idiopathic, or rheumatic
form which Dr. Mackenzie very fully described ;
but among which I am convinced that a closer
study would lead to the distinction of difierent
forms associated with as many differences of con-
stitutional affections.
5. The pygemial.
6. The puerperal ; among which it is probable that
examples of all kinds, only modified by the
puerperal state, are grouped.
Any of these forms of phlebitis may be modified by
occurring in veins already varicose ; but, passing by
these, I proceed to the more proper subject of the paper.
Gouty Phlebitis. — The use of this name is, I believe,
justified by the number of cases in which phlebitis is as-
sociated with ordinary gouty inflammation in the foot or
joints, and occurs, with little or no evident provocation,
in persons of marked gouty constitution or with gouty in-
heritance. In such cases the phlebitis may have no in-
trinsic characters by which to distinguish it ; yet, not
rarely, it has peculiar marks, especially in its symmetry,
apparent metastases, and frequent recurrences. Gouty
phlebitis is far more frequent in the lower limbs than in
any other part ; but it is not limited to the Hmb that is,
294 GOUTY PHLEBITIS.
or has been, the seat of ordinary gout. It affects the
superficial rather than the deep veins, and often occurs
in patches, affecting (for example) on one day a short
piece of a saphenous vein, and on the next day another
separate piece of the same, or a coriesponding piece of
the opposite vein, or of a femoral vein. It shows herein
an evident disposition towards being metastatic and sym-
metrical ; characters which, I may remark, by the way,
are strongly in favour of the belief that the essential and
primary disease is not a coagulation of blood, but an in-
flammation of portions of the venous walls. The in-
flamed portions of vein usually feel hard or very firm ;
they are painful, aching, and very tender to the touch ;
such pain, indeed, often precedes the clearer signs of the
phlebitis, and not rarely begins suddenly. The integu-
ments over the affected veins (where they are super-
ficial) are slightly thickened, and often marked with a
dusky reddish flush. When superficial veins alone are
affected there may be little oedema ; but when venous
trunks, as the femoral, the whole limb assumes the
characteristics of complete venous obstruction. It be-
comes big, clumsy, featureless, heavy, and stiff; its skin
is cool and may be pale, but more often it has a partial
slight livid tint, which may be discerned by comparison
with the other limb, and has mottlings from small
cutaneous veins visibly distended. The limb thus en-
larged feels oedematous all through ; but firm, and tight-
skinned, not yielding easily to pressure, and not pitting
very deeply. By this state almost alone the disease must
sometimes be recognised, for it may be very marked
when only a small })ortion of vein is affected, and that (as
SYMPTOMS, 295
the lower part of the popliteal) so deeply seated as to be
scarcely felt.
The constitutional disturbance associated with this
condition is at most that of slight feverishness, or of an
ordinary gouty attack, more or less acute in different
cases. The effects of the disease I have never had an
opportunity of examining by dissection ; for in the only
fatal case that I have seen, no autopsy w^as allowed. So
far as one may judge of them, by after-events during life,
the veins which may have been obstructed become, in
some cases, pervious again ; for in some instances the
clearing-up of the oedema, and the restoration of the
healthy condition of the limb, are complete. Yet the
veins remain apparently very susceptible : — they ache
exceedingly during fatigue or trivial illness or in
changing weather ; and I have known phlebitis excited
by trivial causes in the same veins three or four times.
In other instances, however (but I think they are rarer
than in other forms of phlebitis), the obstruction of the
veins appears complete, and permanent ; and then, if
they be trunk-veins, the limb remains permanently en-
larged, cumbrous and heavy. Its superficial veins may,
after some time, become varicose ; and others may en-
large for collateral blood-streams ; and I believe that an
increased growth may take place in some of the tissues,
especially the muscles of the limb.
Equally with the other forms of phlebitis, but as
rarely as in any, that which occurs in gout may be fatal
or very dangerous by embohsm. I think that incomplete
pulmonary embolism occurred in two cases in which —
during gouty or rheumatic phlebitis — embarrassed
296 GOUTY PHLEBITIS.
breathing and tremulons action of the heart ahiiost sud-
denly ensued, and then slowly but completely subsided.
In another case such embolism was fatal. A member of
our profession, whom I saw with Dr. Ferguson and Mr.
Morgan, was suffering with a severe and protracted
attack of gout, such as he had had more than once be-
fore. During its course he had signs of phlebitis in scat-
tered portions of the veins of the right thigh and leg
(having previously had phlebitis three times from acci-
dental causes). He was sufficiently recovered to be
down-stairs, and engaged in writing, and thought himself
convalescent ; but having walked up-stairs to his bed-
room, he fell down as if in a deep syncope, and remained
nearly an hour, breathing very faintly, scarcely con-
scious, and with a feeble fluttering pulse. In a few
liours he seemed quite recovered, and next day, and two
days later, we could find nothing additionally wrong
about him, except a fresh attack of similar pldebitis in
the opposite thigh. We examined his chest, and de-
tected only some slight crepitus and faint breathing about
the root of one lung. All appeared going on well for
three days, and he had no sign or warning of severe ill-
ness ; but five or six days after the previous ' fit,' as he
was sitting on tlie night-stool he fell forward, and
rapidly died with a renewal of the signs of syncope and
feeble breathinc^. No examination after death was made,
but from the hkeness of the manner of death to that
which I have seen, in cases of ascertained emboHsm from
systemic veins into the pulmonary artery, I cannot doubt
what happened here. It is probable that in the first fit,
the obstruction of tlie puhnonary artery was partial ; or
TREA TMENT. 297
that the clot was broken up, and its fragments dispersed;
and that in the second, another clot remained blocked in
the main artery, or was heaped on the adherent frag-
ments of the previous clot.^
Gouty phlebitis is often hereditary. A patient, who
had phlebitis in successive patches of both saphenous
veins during an attack of acute gout, told me that his
father and his maternal grandmother were gouty ; and
that, among his relatives on the maternal side, his
mother, two uncles, grandmother, and two cousins, had
inflammations of veins. And I can scarcely doubt that
among the cases of phlebitis which are called ' common,'
and are supposed to be referable to cold, or some wholly
external cause, many might be traced to the gouty dia-
thesis, however diluted and modified in its hereditary
transmission.
In the management of cases of gouty phlebitis, there
has never appeared to me any need of active treatment.
Leeches do no good ; mercury (I think) would do harm,
if anything ; purgatives seem unnecessary ; colchicum
has the same limited value as in other forms of gout, and
appears useful in direct proportion to the severity of the
symptoms. Alkaline drinks are certainly comfortable,
and very probably useful ; and certainly useful are dimi-
nution of food and of stimulants, and an increase of
water-drinking. But more important than all these is
rest, with the trunk and limbs level ; for in this condition
there are the best opportunities for the adhesion of the
^ Mr. Prescott Ilewett in ' Clin. Soc. Trans.' vol. vi., 1873, p. xxxvii.
has given a lucid account of cases of gouty phlebitis, confirming and ex-
tending this description of it.
298 GOUTY PHLEBITIS.
clot, and its union with the walls of the vein, and the
least risk of its detachment. Among local applications
none seem more useful than frequent fomentation and
wrappings of the limbs with hot wet flannels.^
Among the rarest diseases is a phlebitis extending
through large portions of branches of both the superior
and inferior vence cavce. I have seen only one well-
marked case of the kind.
A man, 42 years old, had been ill for three weeks,
when he first came under my care, on October 19th,
1864. I found him restless, looking very distressed,
breathing about thirty times in the minute, but not with
any conscious difficulty, lying on his right side across his
bed. He had pain, and difficulty in moving either arm
or leg (especially the latter). Both arms were swollen,
and oedema tons ; the hands quite bloated ; and both
legs, especially the left below the knee. The ceplialic
vein to the shoulder, and several other subcutaneous
veins of the arm felt like hard, closely beaded cords ; and
had dusky or ruddy marks over them ; but they were
scarcely tender. On the legs all the saphenous veins felt
similarly hard, and over some branches of the right sa-
phena in the thigh there were diffiise branching red bands
and blotches, very tender to the touch, and painful in
movements of the limbs. His tongue was large, thinly
furred, dry along the middle, and at the tip : he was
thirsty and his mouth was all clammy ; he hated food,
^ Lately (1874) I liave setni uiiotlier case of fatal eniboli.sm during con-
vnlepcence after gouty phlebitis, and I have seen and heard of other cases of
embarrassed breathing. See, too, an admirable paper by Dr. Tuckwell in the
last vol. (10th j of the S. Bartholomew's llosp. Reports.
PHLEBITIS OF VEN^ CAV^. 299
but was no longer sick. His pulse was 120, small, and
rather weak ; his breathing as above noted. The heart's
sounds were natural ; so were the percussion and respira-
tory sounds over all the front of the chest. Over the
lower half of the back of the right lung percussion was
all dull, and there was a moderately fine crepitation
audible to the same extent. The same kind of crepita-
tion was in the lower and posterior third of the left lung ;
but here there was a less deoxee of dulness. The skinf
was moist ; at the head rather hot, and perspiring, at
the hands cool. The bowels appeared disposed to act
regularly, but were confined by the opiates he took.
His mind was quite clear. All the signs of pneumonia
with increase of the pulse from 80 to 120 had come on
during the last twenty hours. He was advised to take
fifteen grains of Dover's powder at bedtime, and to con-
tinue the use of chlorate of potash and ammonia, with
some bark ; and about ten ounces of wine, and some beef
tea, and to remain in perfect rest.
October 20. — He passed a very restless night, with
frequent delirium. This evening his pulse was weaker,
very soft and feeble ; his breathing more free, but of
about the same quickness. His abdomen was rather dis-
tended ; he had had all day frequent hiccough, and had
been sometimes sick. He sweated profusely, almost con-
stantly, especially at the head ; and had a short shivering
fit in the morning. His general strength appeared much
lower. The swelling of both legs was increased, and the
fore part of the left foot was dusky-blue, cold, insensible
— evidently gangrenous. Thus it had been for about 12
hours. The femoral pulse corresponded with the radial :
300 GOUTY PHLEBITIS.
the pulses of the tibials could not be felt on account of
the oedema. From this time he rapidly became weaker,
and without any marked new symptom, unless it were
commencing gangrene of the left hand ; he died at 1 p.m.
on the 21st.
The history of this case, for which I am indebted to
Dr. Corbould, was that the patient had been an active
and generally healthy man, till five years before, when
he had Smyrna ague, followed by a severe attack of
'Aleppo buttons.' From that time he had had less good
health than before, and had often boils ; and whenever
he was unwell, was apt to have chills, and feverish
attacks reminding him of his old Smyrna ague. His
family had no known disease, except consumption. Of
his children, three had died recently in an epidemic of
Scarlet Fever, and it was believed that a drain ran inider
his house (at Sydenham), but there was no clear evidence
of this.
His illness was of three weeks' duration and began
with irregular chills, and a fit of shivering, and heats,
and sweatings, which he regarded as a renewal of his old
malady. After a few days he had soreness of the
throat, which went on until a large abscess formed
in one tonsil. It was opened, and discharged freely.
All this part of his illness was attended with an
ordinary amount of fever, and much sweating, but with
no unusual symptoms. About a week before his death,
without any accession of otiier new symptoms, the
affection of his cutaneous veins bcG^an. Those of the
arms were first affected, then those of the legs. First,
part of the course or branchings of a vein would be
PHLEBITIS OF VENjE CAVJE. 301
marked with rather diffused red vascular bands (Hke those
common over inflamed lymphatics) ; and with these
were pain and tenderness. Then the vein would feel as if
becoming hard, and at last quite hard, and closely
knotted ; and with this change the discoloration of the
skin would gradually change to dusky brown, or nearly
black, and then slowly disappear.
In both the progress and general distribution of the
disease in the veins, there was an evident plan of sym-
metry ; and usually the progress was from superficial to
deep veins, and oedema followed at a distinct interval, the
external signs of phlebitis.
The body was examined by Mr. Morrant Baker, who
gave me the following report of it : —
Post Mortem examination. — Left leg. — The long
saphenous vein was plugged with coagulated blood,
apparently in its whole extent. The femoral, popliteal,
posterior, and anterior tibial veins were in the same
condition ; and so were their branches, muscular and
others, as far as was seen, either in dissecting them out,
or whenever they happened to be cut across. Here and
there the colouring matter of the blood had oozed through
the femoral vein, and stained the coats of the artery, and
other neighbouring parts.
Left arm. — The radial, and other superficial veins of
the hand and fore-arm were plugged in the same manner
as those of the leg ; and on dissecting out the brachial
artery, its vense comites were found in the same state.
The deep radial, and ulnar veins were not examined, but
they were doubtless in a similar condition.
The external iliac, common iliac, and inferior cava
veins were healthy, and free from clot.
302 GOUTY PHLEBITIS.
The coats of the plugged veins appeared somewhat
thickened, and the clots, which completely filled and
uniformly distended them, were slightly adherent to their
lining membrane. The right limbs were not dissected,
but there appeared no reason to doubt that their vessels
were in a like condition to that which has been described
as existing in the left.
The arteries were apparently quite healthy, and every-
where in the limbs, as far as they were seen in dissection,
entirely free from clot. They were traced down to the
gangrenous part of the left foot, and here also were found
quite pervious.
The heart was very flabby and fatty, but with no
other disease than this, and all its cavities were remarkably
free from either fluid or coagulated blood. Their lining
membrane was deeply blood-stained. The pulmonary
arteries on both sides were pervious and empty, excepting
one branch of the right, which contained a small clot,
apparently recent. The substance of both lungs was
here and there emphysematous, and throughout con-
gested and very oedematous. No secondary deposits
were seen in any part of tliem. The right pleural
cavity contained a considerable quantity of deeply
blood-stained fkiid. The liver was pale and fatty ; ap-
parently not otherwise diseased. The kidneys were
flabby, soft, pale, and fatty.
I cannot venture to say on what, if on any, manner of
blood-poisoning the developinont of this singular disease
depended. It may be only by chance that, in the only
other case at all resembling it that I have met with, there
was also some reason for believing that the disease had
PHLEBITIS WITH FEVER. 303
its origin in poisoning with foul air from a drain. This
was the case of a clergyman, Mr. A. ; a generally healthy
man, with no known tendency to disease. In 1859 he
superintended the opening of an old well, which proved
so foul that it was at once closed again. Two of the
men who had worked at the well were ill for some days
after, with sickness, headache, and depression : and he
himself felt slight nausea, for which he took a little
brandy. A few days subsequently, and after a fatiguing
journey, he had what appears to have been an attack ol
pneumonia, accompanied with fever and difficulty of
breathing, and for which he was treated with leeches, and
poultices. In about ten days, considering himself much
better, he went down-stairs, but on reachinej the drawino*-
room was suddenly seized with such excruciating pain in
the left leg, that he was obliged to go to bed again ; next
day he was told that he had phlebitis. The attack of
phlebitis soon subsided, and he returned by easy stages
into the country.
A few days after this he was seized with ' low fever :'
this lasted six weeks, and was attended with alarming
symptoms ; rapid pulse, great heat of skin, unconscious-
ness, and delirium ; and slight haemorrhage from the ears,
and nose, and from the stomach, bladder, and intestines.
Durin<? a linserino; convalescence from this illness there
was great swelling of the legs, especially of the right (the
left having been the seat of the previous phlebitis) : ' a
fearful straining sort of pain in the region of the left
kidney ; ' and a frequent recurrence, for about ten days,
of ' most violent shivering fits, succeeded by fever, and
profuse perspirations.' There were frequent, and violent
304 GOUTY PHLEBITIS,
fits of liiccougli ; and ' the throat was covered with an
appearance of thrush of a yellowish-white colour/ At
length Mr. A. regained his ordinary health. Thus the
case ended with apparently complete recovery from the
extensive inflammation of the veins of the lower limbs
(and as we may assume), of those of the kidneys, intestine,
and other parts from which ha3morrhage occurred. But
ever since, there has remained a singular readiness for
phlebitis in the trunk, and lower limbs. Thus in Sep-
tember 1861, after an unusually long walk, Mr. A., on
examining a tender spot on the inner side of the right
le^r, found a red streaking^ of the skin over the internal
saphena vein, with a hard cord-like condition of the
vessel, for about two inches of its lens^th. With
horizontal rest this phlebitis, which did not extend
itself, passed off. In the beginning of December in the
same year, phlebitis occurred in the veins of tlie right
groin, and spread to those of the abdomen, producing
tenderness and redness of the skin, and leaving, as tliese
passed away, a bruise-like discoloration of the surface.
The veins affected in this attack remained much enlarged,
and varicose. During the autumn of 1864, Mr. A., after
a fatiguing walk, discovered a small inflamed spot in a
vein of tlie left groin, and from this centre phlebitis
spread throughout all those veins of the abdomen whicli
liad remained varicose from the attack in 1861. At the
end of three weeks tlie aflcction suddenly left tlie
abdominal surface-veins, and fixed itself in those of the
inner side of tlic right thigli, causing considerable pain,
and for the time, wholly disabling the limb. Treated
with entire rest of tlie part in the horizontal posture, the
GOUTY PHLEBITIS, 305
disease subsided, and Mr. A. was well again, and able to
take clerical duty till January 1865, when, after some
precursory tenderness, the fourth onset of phlebitis
showed itself in the veins of the right calf. This was of
short duration, but left the limb much weakened.
In strong contrast with these cases of widely dif-
fused phlebitis, are those in which a single small portion
of a great vein becomes obstructed. I have referred to
some of these as occurring in connection with gout ; but
I have seen other instances which, though no trace of gout
or other general disease could be detected in them, may
serve for illustration of some points in the local pathology
of gouty phlebitis.
A man about 50 years old, thin, and moderately
muscular, and usually healthy, observed, during a
September, that his right arm was growing larger, and,
as he thought, stronger, and fitter for work. But, as it
still increased, it became inconveniently heavy, and
certainly weaker : and then he applied for advice. I
found the upper arm two inches more in circumference
than the left, and the whole limb enlarged in the same
proportion. It looked full, round, and muscular, and
felt firm, and oedematous, not only in the subcutaneous
tissue but throughout ; the skin was tense, cool, and pale.
In nearly four inches of its course the axillary vein felt
large, hard, and cord-like ; and in one or two spots over
it pressure caused pain : but with this exception no pain
was felt in any part of the arm. Some of the superficial
veins in the arm, and over the upper and front part of
the chest, were enlarged, and when the arm hung down
for a long time the hand became dusky. No cause
X
3o6 GOUTY PHLEBITIS.
whatever could be traced for this condition : no injury or
pressure ; no known inheritance of disease ; no dis-
turbance of the general health, past or present.
With the help of the hot douche, warmth, and
friction, the swelling of the arm very gradually subsided ;
and, as it did so, the cord-like feeling of the obliterated
axillary vein became more distinct. A year elapsed
before the vein regained its completely natural condition ;
but it has now for more than five years been well.
Very similar to this case was that of a regimental
servant, 27 years old, previously healthy, and very active,
who was sent to me on April 12th, 1855, by Mr. Bossey,
on account of the condition of his right arm. This was
swollen, and, when it hung down, he had a feeling of
weight and fulness as if the blood could not return from
it. The arm was indeed about a quarter or a third
larger than the other ; but its chief enlargement felt as if
due to great muscular development. Besides this,
however, it had probably some general swelling, which
might be from slight oedema of its deeper tissues ; its
subcutaneous veins were all over-full ; there were small
bluish spots over the deltoid, as if from small clusters of
varicose veins, and the veins over the right pectoral
muscles were fuller than those over the left. This
condition of fulness extended as high as the deltoid's
origins : — the slioulder especially was remarkably broad
and large, and there were fulness and some prominence of
the upper part of the riglit great pectoral. Tlie heart's
action and sounds were natural ; so was the pulse at both
wrists, equal and moderately full. It was uncertain how
long this state of tlie arm had existed ; it had been
GOUTY PHLEBITIS. 307
observed only a week ; its rate of increase was unknown.
The patient remained in about the same condition till
May 4th, when he was taken into the hospital, and
ordered milk diet ; six leeches every third night ; and
three grains of mercury with chalk every night and
morning. He was under this plan for about a fortnight,
and certainly improved, the arm decreasing, and its veins
becoming less full. Then he had an attack of scarlatina,
and while this was running its course all signs of the
aiFection of the arm disappeared. It regained its natural
size ; the veins were scarcely fuller than in a healthy
man ; he lost the sensation of numbness, and believed
himself well at the end of May.
A marked feature in both these cases was the
apparent, and, I believe, real enlargement of the muscles
of the limb. I referred to this in a paper published in
the ' Medical Times and Gazette ' of March 1858, and
soon afterwards received a letter from the late Professor
Laurie of Glasgow, from which the following is an
extract : —
' I am the subject of one form of that peculiarity
which I suspect is not very common, and which depends,
as you hint, on diseased or varicose veins.
'In the year 1831, I had an almost fatal attack of
Typhus. During convalescence, I was seized with
phlegmasia dolens of my left lower limb, attended with
exquisite pain in the ham and calf. When the pain
subsided, and I commenced to leave my bed and dress, I
was astonished to find that while my right thigh and
leg were emaciated, as they usually are after such an
illness, my left was nearly, if not actually, as large as
X 2
3o8 GOUTY PHLEBITIS.
when I took to bed. It was not in any way mis-shapen,
C)r oedematous — simply phnnp, and full sized. When I
recovered so far as to be able to walk, I found the veins
enlarged, and, by night, the whole limb oedematous, but
in the morning the soft swelling had disappeared, and the
muscular enlargement round the calf remained. The
excess Avas at least an inch. For many months I was
unfit for much walking ; indeed, but for a large laced
stocking, I should have been compelled to relinquish my
profession. I wore one for two or three years, and then
was able to lay it aside, but as I got older, I was obliged
to return to its use, and for years back I have worn an
elastic stocking. The veins are now decidedly varicose,
and the limb becomes oedematous after unusual fatigue.
The soft swelling readily disappears under rest, and, as
formerly, the muscular enlargement remains. It is,
however, now less obvious than formerly, as I am
unhappily much less muscular than I was ten years ago.'
The occurrence of acute phlebitis during, or at the
beginning, of pysemia is well known. It is, I think, less
considered that cases of the less acute forms of phlebitis
are frequent after all the suppurative phenomena of
pysemia have passed by. Some instances of this were
related in the last volume of the Eeports (vol. i. p. 5). I
would not maintain tliat such cases are peculiar sequences
or residues of pyyemia. They may ratlier be reckoned
among a class of cases of what may be called ' post-febrile
phlebitis ; ' for after any illness attended with acute fever,
and often without any very marked exhaustion, it is not rare
to find one or more veins of the limbs becoming almost
GOUTY PHLEBITIS. 309
suddenly painful and hard, and then to see oedematous
swelling of the parts beyond them. Such attacks of
phlebitis seem especially common after typhoid fever.
They usually subside without treatment. Among many
instances, I have seen nothing worse than an interruption
or a delay of convalescence, followed by permanent en-
largement, but not disability, of the limb.
The overgrowth of parts whose veins are obstructed,
to which I have referred, is very notable in the rare
instances of phlebitis in young children. I have lately
seen a child five years old, whose right lower limb has
for three years been growing larger than the left. In the
day, and when long dependent, it becomes oedematous ;
but during the night the cedema disappears, and the
limb only looks much too large. Many parts of the
thigh are mottled, dusky, and pink, and part of the skin
at the knee is coarse-textured and warty. The whole
aspect of the limb is like that of the limbs of adults in
which, as in Professor Laurie's, the femoral or common
iliac vein has been long obstructed. One might suppose
it a case of simple hypertrophy, but that the limb is cold,
not over-warm; or one of obstructed lymphatics, with
growth from retained lymph, but that the blotches on the
skin are characteristic of obstructed veins.
3IO
RESIDUAL ABSCESSES,
Undeu the name ' residual abscesses ' I would include all
abscesses formed in or about the residues of former in-
flammations. Most of them are formed where pus, pro-
duced long previously, has been wholly or in part retained
and become dry, or in some form ' obsolete.' But some
of them, it is probable, are formed in the thickenings,
adhesions, or other lowly organised products of inflamma-
tion long past.
Abscesses thus formed are probably well known to
many ; but, to give them a name and separate illustrations
may help to show that they are of more frequent occur-
rence than is commonly supposed, and are often impor-
tant in diagnosis.
Suppuration among the products of a fonner inflam-
mation is probably an illustration of what may be held as
generally true concerning many relapsing inflammations,
namely, that they are due to the disturbed or interrupted
nutrition, not only of the tissues deteriorated in previous
inflammations, but of the new materials that were formed
among them. Thus, in the frequently relapsing inflam-
mations of testicles, and joints, and other parts that one
aees in a constantly ' fretful ' state, the ' weakness,' ' low
RESIDUAL ABSCESSES. 311
vitality,' or ' want of tenacity of composition,' which are
indicated by infiammation under every shght provocation,
are to be ascribed rather to the remaining products of
former inflammations than to the original textures of the
parts. Thus adhesions become inflamed, and residues of
pus, degenerating under irritation, initiate or take part in
a renewed suppuration.
Some of the most striking instances of residual
abscesses may be found in connection with diseases of the
spine.
A patient about 40 years old had, as was supposed,
acute pleurisy ; but it may be believed that, whether with
or without pleurisy, she had acute caries of the spine, for,
when she had recovered from the pain and other severe
signs of her malady, a very prominent angular curvature
of the lower dorsal part of her spine was found. She
remained in feeble health with various evidences of scro-
fula, but no new disturbances appeared at or near her
spine till about six years after the formation of the angular
curvature, when a large lumbar abscess formed. Its
formation was attended with very little disturbance of the
general health, and it remained nearly stationary for
nearly two years and then disappeared and gave no further
trouble. Subsequently a scrofulous necrosis of the tibia
ensued, and about a year later death occurred in acute
bronchitis.
I suppose that in this case the abscess formed in or
about the residue of inflammatory products which had
been at rest for six years. The supposition is justified by
two similar but clearer cases.
312 RESIDUAL ABSCESSES.
A lady about 30 years old had well-marked angular
projection of the last two lumbar vertebrge and a psoas
abscess, which extended far down the outer part of the
thigh, and might be estimated to contain at least two
pints of pus. She had not suffered severely during the
progress of the disease, but was very weak and wasting.
I advised her to remain in perfect and constant rest on a
couch, and to be carefully nourished, and kept as nearly
as possible in good general health. At the end of two
years, during which this plan was carefully carried-out,
the abscess, having slowly diminished, had disappeared.
Nothing could be felt but what might be considered
shrunken and hardened abscess-wall, and the patient was
fat and strong. She resumed active habits of life, and
among other feats of good health walked to the summit
of the Eighi and some other Swiss mountains. Thus she
continued well and vigorous for four years ; then she had
a severe and tedious bronchitis, and became very weak,
and an abscess as large as the previous one quickly
formed. Again she rested for two years, but with no
other advantage than that of regaining the strength lost
during the bronchitis. The abscess slowly increased, but
with very little constitutional disturbance ; and at the
end of two years and a half from its appearance, it opened
spontaneously and discharged. It is still, after more than
two years, discharging : but the general health appears
sound and recovery most probable.
A gentleman about 20 years old had what was
believed to be acute pelvic or iliac inflammation, but,
after some peril of his life, recovered and was able to
practise actively in the law. Twenty years afterwards he
RESIDUAL ABSCESSES, 313
began to suffer with various intestinal distresses, and
with pains in the back and hmbs, which, as he watched
and described them very scrupulously, led to his being
thought hypochondriacal, till a large abscess appeared in
the upper part of his right thigh. After this a lumbar
abscess also appeared, and discharged into the intestine
while that in the thigh discharged externally. He slowly
wasted with hectic and after about two years died : and
the examination showed that the abscesses were connected
with old carious disease of the bodies of the lumbar
vertebrae. The carious bone had become hardened and
smooth, and bridges of new bone had formed connecting
the bodies of the vertebrae, which were so hard and com-
pact as to leave no reasonable doubt that they were
formed during and after the illness which occurred
more than twenty years before death, and which had
been followed by at least fifteen years of health and
apparent soundness of textures.
The state of parts in the intervals of suspense in these
cases, as well as much of the general history of residual
abscesses, is illustrated by a specimen in the Museum of
the Hospital.^ It shows two psoas muscles with cavities
occupying the place of their whole interior substance.
The cavities, walled-in by the thin remains of muscular
substance, and lined by thin membranes, were filled with
the half-dry remains of pus. Externally the muscles
appeared healthy, except in being pale ; they were of
natural size, and the adjacent structures were all healthy,
unless for a very slight superficial roughness of the body
of one lumbar vertebra.
* Series V., No. 30, represented in the * Hospital Reports/ vol. V., pi. I.
314 RESIDUAL ABSCESSES. '
The history of this case is not known : the specimens
were taken from a body sent to the dissecting rooms ; yet
it is plain enough that two psoas abscesses were formed,
that they failed of being discharged, and that the retained
pus withered and became half dry and obsolete ; and it is
equally plain that parts left thus unsound must have been
very susceptible of fresh inflammation, and if inflamed
would have become the seats of residual abscesses, such
as formed in the cases I have related.
Collections of withered and half-dried pus, similar to
these, may be found not rarely near joints long ago
diseased but now quiet. They are sometimes seen during
excision of the knee, especially in cases in which the
operation is done, not for any great severity of disease,
but for repeated disabling relapses of inflammation in a
joint without evident suppuration. Similarly, an abscess,
long quiet, but with pus little changed, was found in the
following case : —
A woman nearly 30 years old, in good general health,
was admitted under Mr. Stanley with a circumscribed
swelling over and above the left sacro-iliac symphysis,
painless and elastic. It was thought to be a fatty tumour,
but the operation begun for its removal let out pus from
a cavity leading, by a narrow track, to the hip-joint.
Disease of this joint had existed twenty years previously,
and had subsided, without apparent suppuration, after a
year's rest. The patient had remained lame with stiff-
ness of the joint, but with no other distress ; and the
abscess had not been observed for more than two years
before it was opened.
Cases of residual abscess such as these are sometimes
RESIDUAL ABSCESSES. 315
the cause of disappointment in cases of diseased joint,
especially of diseased hip-joints apparently repaired with-
out suppuration, and remaining, to all appearance, well
for one or more years.
A woman 25 years old, healthy and strong, came with
abscess over the left hip-joint. When 11 years old she
had disease of this hip, followed by nearly two inches
shortening of the limb. At 18, after a very long interval
of apparent recovery, a swelling formed under the sheath
of the femoral vessels, and now at 25 it contained half a
pint of fluid, which one could not doubt was pus. The
swelling was painless, and was slowly increasing without
any disturbance of the general health. It was left for
spontaneous discharge.
A student, 20 years old, related that he had often, in
early life, had scrofulous disease of the cervical glands,
and when he was 13 had inflammation of the left hip-
joint, which, without apparent suppuration, was followed
by shortening of the limb to the extent of about three
inches. Of these three inches about half was due to
defective growth of the limb, the remainder to ulceration
or absorption of the head and neck of the femur. But
the new-formed joint, if such there was, was freely
moveable and so sound that, for the last five years, he had
been constantly gaining strength in the limb and living
actively without pain or illness.
During the last ten months he had observed a gradu-
ally increasing swelling in the upper and outer part of the
thigh, but it gave no pain or trouble till, within the few
days before my first seeing him, the skin over it inflamed.
The swelling felt now like a chronic abscess pointing, and
3i6 RESIDUAL ABSCESSES.
after a few days' treatment was punctured. About ten
ounces of thick pus were let out. No fever or other
serious disturbance followed, and the abscess-walls gra-
dually contracted, leaving a sinus four or five inches long
leading towards the remains of the acetabulum. To heal
this, tincture of iodine was injected. Three days after-
w^ards rigors and a sharp attack of fever ensued, and
these were followed by swelling and pain about the sinus,
and then by a copious discharge of ' chalky ' matter and
thick pus.
A large quantity of this chalky matter, which could
only be regarded as a residue of pus formed ^^^ or more
years previously, in the earlier stages of the disease of the
joint, was discharged with fresh-formed pus and small
fragments of cancellous bone. After many months the
discharge diminished, and only a long sinus remained ;
but signs appeared of tuberculous disease of the genital
and urinary organs, and with this the patient died — about
nine years from the first indication of disease of the hip-
joint, and about three years from the first appearance of
the residual abscess.
Another group of cases which I believe may be re-
ferred to residual abscesses are found among instances of
necrosis of the interior of loncj bones. Two remarkable
examples have lately been in the hospital.
In February last a woman, 38 years old, was in Sit well
Ward under my care, with what I believed to be abscess
in the head of the tibia. There was general swelling at
the part, with heat, and at times such pain as the patient
called ' frightful,' and ' agony.'
RESIDUAL ABSCESSES. • 317
When she was ten years old — that is, twenty-eight
years before admission — she had inflammation of the leg
in consequence of a fall, and this was followed by ex-
foliation of several small portions of the upper part of the
tibia. They were discharged through abscesses or sinuses
which remained open for five years, and in or about
which many attacks of inflammation occurred. At the
end of these five years the patient appeared well : and
so she remained for twenty years, leading an active life
and feeling no pain or distress in the limb. Three years
before her admission, in consequence, probably, of over-
fatigue, the leg began to be painful and slightly swollen
about the upper part of the tibia ; and from this time
onwards she suffered, especially in winter, from the fierce
attacks of pain for which she came to me.
Shortly after her admission, I perforated the head of
the tibia at the place of most intense tenderness, close by
some of the scars of the openings from which sequestra
had been discharged. The drill entered a small abscess-
cavity and a few drops of pus escaped. The operation
was followed by complete release from pain.
In the next bed to this patient was a girl 13 years
old, who had had similar necrosis in the upper part of the
tibia following injury five years previously. At various
times sequestra had been discharged, or removed : then
followed an interval of apparent health, and then abscess,
such as might be called residual, in the cavity that had
contained sequestra. This abscess was perforated and
slowly healed.
In 1860 I saw, with Mr. Edgar Barker, a lad 14
years old, who, fifteen months previously, had acute
3i8 RESIDUAL ABSCESSES.
periostitis and necrosis of both tibios at and about the
junctions of their middle and lower thirds. I removed
portions of the inner layers of the walls of both the tibiae :
the sequestra being almost as symmetrical as the disease
had been : both lying in similar cavities in the walls and
with similar cloacas. The wounds healed favourably and
all appeared well for nearly seven years.
At the end of this time, the patient's general health
having been much reduced during residence in China,
abscess slowly formed at the lower part of the right tibia,
and I had to perforate it. The abscess cavity was evi-
dently in or very near Ihat from which the sequestra were
removed seven years before. The wounds of the operation
healed, but the tibia is still frequently inflamed.
In none of these cases did I find distinct residues of
pus in the cavities from which sequestra had been re-
moved and in which, long afterwards, suppuration ensued.
Yet it is highly probable that, with stricter search than is
possible during an operation, such residues would be
found : for the condition of sequestrum-cavities, with
rigid walls and suppurating linings, is just that in
which we might expect an incomplete filling up with
new tissue, and remaining spaces filled with residues of
pus.
Many other cases might be cited of residual abscesses
with histories and characters closely resembling those just
related. Thus, in lym})hatic glands remaining large and
indurated after scrofulous inflammation in early life, it is
not rare to see, many years later, fresh inflammation fol-
lowed by abscess and discharge of thick caseous and
RESIDUAL ABSCESSES. 319
calcareous matter, the residues of the earlier inflammatory
formations. And by the rectum, hardnesses, remnants of
inflammation threatening or producing abscess, are nearly
sure to suppurate, though many years of apparent
quietude may elapse. I have thus known an interval of
14 years elapse between the healing of an abscess by the
rectum and a renewal of suppuration in the residue of
scar and unsound tissue which it left.
Taken together, these cases may suffice to illustrate
the general fact that abscesses are very apt to form in the
seats of inflammations long past, especially where residues
of pus remain. Such residual abscesses may form, as in
the seats of past necrosis, with all the pain and constitu-
tional disturbance commonly attendant on acute abscesses ;
but much more frequently they form slowly and without
pain or fever or any other distress. In these cases they
acquire great interest from the difficulty of diagnosis.
They may resemble burs^e or fatty or fibro-cellular
tumours, and only a carefully ascertained history of the
case may suffice for their discrimination. On the ground
of history, a residual abscess may be suspected whenever a
swelling, not altogether unlike an abscess, appears in or
near a part that has long previously been the seat of an
inflammation, especially if it appears or greatly increases
soon after anything that has impaired the general health.
In the treatment of residual abscesses, no other rules
need be observed than those generally accepted for the
treatment of ordinary acute and chronic abscesses. I
have only once seen a residual abscess disappear without
discharge : and the probability of such an event is so
slight that I would rather promote than retard their
320 RESIDUAL ABSCESSES,
suppuration. But as to the time and manner of opening
such abscesses, and the after-treatment, the general rules
for the management of ordinary abscesses may suffice.
Many of the cases I have related are instances of the
very long time during which a part once damaged by in-
flammation may remain unsound : and the disappoint-
ment felt on the occurrence of a residual abscess may, to
some, seem to cast discredit on the practice of permitting
or aiding the absorption or drying-up of chronic abscesses
connected with disease of spine or joint. But the dis-
credit would not be just : for many patients in whom
such abscesses have disappeared have never suffered
after-consequences : and, so far as I have yet seen, the
healing of discharged residual abscesses is quicker, and
attended with much less disturbance, than the healing of
first abscesses of the same size and in similar situations.
321
ON DISSECTION-POISONS.
The subject of dissection- wounds has, of late years,
seemed less important than it was thought to be some
thirty years ago. When I was a student, it was believed
that such w^ounds were not rarely fatal, and that fre-
quently they led to severe disease. Now, they are often
made light of. My recent illness disposes me to think
this levity misplaced. It is very improbable that there
should be any change in the virulence of poisons generated
in the dead body ; and if there be any change in the
consequences of inoculation with them, I should think it
due to the changes in the manner of treating them. In
my student-days the first signs of inflammation following
such wounds were generally treated with leeches, purga-
tives, spare diet, and other depressing means ; now, as
for many years past, the prescription is good food, wine,
rest, and, above all, fresh air. You may be certain that
this is the better prescription ; and I believe that if I
could have availed myself of the whole of it, especially
of the last two ingredients, I should have averted most of
the troubles that I have lately suffered.
Let me now speak to you about these troubles. And,
first, as to their source and the conditions on which they
Y
322 ON DISSECTION-POISONS.
depend. The material with which I was infected was in
the dead body of the patient on whose case I last lectured.^
He died after hthotomy, with acute celluhtis at the back
of the pelvis, and with acute pleurisy ; both of which, I
believe, were of pysemial origin. The grounds for this
belief I stated to you when, at the last lecture, I showed
you the morbid structures removed after death. I refer
to it now only that I may remind you of the probability
that the inflammatory products of pysemial disease are
especially virulent after death. The most dangerous
examinations appear to be those of women who have
died with puerperal peritonitis ; and most of the cases
thus named are pygemial. I can only suspect that the
material which poisoned me was in the pleuritic fluid, in
which my hands were long soaked ; but what the poisonous
material — the virus — was, neither this, nor any record of
similar cases, enables me to tell.^
Whatever the virus was, it soaked through my skin ;
I had no wound or crack of any kind. Mr. Young, who
began the examination, cut himself and suffered no harm.
I had a sound skin, but one not impenetrable, and through
it the virus worked its way. Mr. Young did what I
advise you to do in any similar case. He washed his
hands, sucked the cut part, made it bleed freely, and then
took care of himself, and did not rub the cut part with
» It is recorded in ' The Lancet ' of May 27, 1871, p. 711.
^ A sad instance, in proof that it is not any ordinary decaying or de-
composing animal mutter wliicli tlms poisons, has lately occurred. One of
the Museum-strvants in tlie Colk'ize of Surgeons, who had rarely passed a
day during several years without frequent contact with animal bodies in all
stages of decomposition, with macerating bones and preparations in spirit,
took fin appointment in the anatomical school of St, Thomas's Hospital. In
a fortnight he wounded himself while })reparing for dissection the body of
u child dead of pyaemia. In a few days he died of septicaemia.
VIRUS: ABSORPTION. 323
nitrate of silver. He thus reduced his risk to less than
that of the absorption of virus through sound skin.
This absorption is generally spoken of as if it were a
strange and rare fact. Eare it may be, but strange it is
not ; for thus it is that, most commonly, the poison of
chancre passes through skin and that of gonorrhoea
through mucous membrane, and thus that the irritant
matter of cantharides and other skin-irritants passes to the
cutis, and from it may be absorbed. A v^ound or a
crack that exposes a vascular surface is doubtless very
favourable to infection by any virus ; but it is not
essential ; I wish it had been and were still so.
Thus, then, this virus passed into me ; and I will tell
you presently some of the mischief that it did. But first
let me say that this mischief would not have happened
but that there was in me something that made my blood,
or some of my textures, susceptible of such diseased
processes as the virus could excite. For not all men can
be made ill by a virus from a dead body, nor can the
same man be made ill at all times ; but there must be
what is called a fitting soil for the virus to work in. We
know no more what this soil is than we do what the
virus is ; we have to use figurative expressions ; but we
need not doubt that they imply facts, and that, for any
living body to be made diseased by a dead one, there
must be certain living materials which can be diverted by
the dead ones from their normal relations and turned
into a morbid course.
A chief interest, in reference to these various suscep-
tibilities of the influence of virus from dead bodies is, that
one may become insusceptible. They who are day after
Y 2
324 ON DISSECTION-POISONS.
day engaged in dissections or in post-mortem examinations,
usually acquire a complete immunity from the worse
influences of the virus. They may suffer local troubles
from it, and some among them may get that curious
warty affection of the skin of the hands or fingers which
Dr. Wilks described in the ' Guy's Hospital Eeports ; ' ^ or
they may lose health through the influence of bad air or
over-work ; but they do not suffer with any infection of
the lymph or blood.
Such an immunity as this I enjoyed when I was
demonstrator of morbid anatomy, and made almost daily
post-mortem examinations. It mattered not what was
the disease of which the examined body died, or what was
the state of my skin, sound, or cracked, or wounded :
nothing hurt me ; and this immunity lasted many years.
A similar immimity in the case of many fevers is
possessed by those who have passed through one attack.
It is, as you know, very rare to have a second attack of
scarlet fever or of typhus ; and it is, perhaps, more rare
to liave a second indurated chancre, or a second complete
series of secondary symptoms. In these cases we believe
that the first attack alters the blood or tissues in such a
maimer that they are no longer susceptible of the same
morbid changes as they were, even though in all other
respects they appear unaltered. But I think it is not in
this way that tlie immunity from tlie infections of dead
bodies is obtained ; for though few demonstrators or
others constantly engaged in morbid anatomy escape quite
unscathed, yet some do so ; and these may be enougli to
prove that the immunity is acquired by what we may call
1 3idSer: Vol. viii, p. 263.
IMMUNITY. 325
custom. Just as a man, beginning with small quantities
of strong drink, and gradually increasing them, may never
get drunk, even though he may at last drink hugely too
much ; or as a Styrian (if the stories be true) may take
arsenic till he can hardly be poisoned with it ; so may
any one by custom become insusceptible of the evil effects
of the corpse-poisons. It may be that his blood and
tissues become less alterable by alien matters, or that the
living parts acquire more power of assimilating or of ex-
creting the dead materials that are introduced among
them : how it comes to pass we cannot surely tell, but
the fact of an acquired immunity seems certain.
I wish some of you would study these immunities
more closely than any one has yet done. They are of
infinite interest in physiology, for they show a striking
contrast between dead and living things. Gutta cavat
lapidem is a, pattern of many proverbs that express the
popular knowledge that all dead things yield to the re-
peated application of small forces ; yet living things rather
strengthen themselves against such forces. Not that this
or any other contrast between dead and living things is
absolute or constant ; yet this, like all the rest, is worth
most careful study. And of still more interest in pa-
thology are these acquired immunities ; for as yet we
know scarcely more than the bare fact. Some immunities
are local — such as that of which anyone will tell you who
has had a long succession of blisters on the same place.
He finds that at last he can be bhstered there no more ;
yet you may blister him on some other part. And such,
I suspect, is the immunity from the virus of soft chancre
which may be obtained through frequent inoculations ;
326 ON DISSECTION-POISOXS,
but of this I have had no experhnental knowledge. I
think, however, that I have had personal knowledge of
acquired immunity of another kind of inserted poisons —
that, namely, of fleas, bugs, and the like pests of vacation-
life. Let me commend this subject of study to any of
you who are not unwilling to be martyrs to science, I
think you will find, as I have found in some continental
tours, that for the first night you may be driven half wild
by the vermin of the bed' or of the air, but that after a
time you care less for them, and that at last you become
indifferent to them ; not because they leave you alone,
but because their virus no longer irritates the blood or
the textures that at first fiercely resented it.
This instance may seem a trivial one ; yet I believe
that in it you may find illustrations of much more serious
things, even of that doctrine of syphilisation of which you
have heard so much.
But now observe : this immunity, it seems, may be
gradually lost, just as that after vaccination may be ; the
influence, as the expression is, gradually wears-out. My
case is evidence of this. Years ago no virus of a dead
body could hurt me ; but then came a time in which I
made few or no examinations after death. I stood by
and watched others making them ; and I became again
susceptible to poisons that were once innocuous. My
blood and textures regained the state they had before
ever virus was introduced into them, and I became again
more poisonable.
Think how curious a fact this, which is only one of a
large class, is. Being more susceptible of morbid influ-
ences, one seems less healthy ; but, in truth, one has
REGAINED SUSCEPTIBILITY, 2,^7
become more healthy. Just as after vaccination, or after
scarlet fever, one's blood or textures, or both, being so
altered that the same poison will no longer act on them,
seem the better for the change ; yet they are morbidly
altered.-^ And then, for years afterwards, by the exact
assimilation of the nutritive process, they are maintained
in the same morbid state ; like a scar which, useful as it
is, is yet a morbid structure. And as a scar, if not too
deep, gradually wears out — that is, gradually reverts to
the healthy skin-structure, — so is it with the blood and
textures of the once infected person. Eecovering their
natural condition, they become again susceptible of
infection ; becoming again healthy, they become what
may seem weaker, and are more liable to disease.^
Think, again, of the long time during which facts like
these prove that a process of recovery from disease may
continue before it is perfect. The years through which
a man must pass before he becomes liable to a second
attack of these diseases tell the time that is required for
his complete recovery from the first. Let the fact teach
1 Some opponents of vaccination have used this and a similar expression
in my Lectures on Pathology as if they implied a mischief in vaccination.
None but a silly or dishonest person could so use them : but with a very
few strange exceptions it is only by such persons as these that vaccination is
opposed.
* The circumstances of an illness which Dr. Symes Thompson suffered
many years ago, and which he has described in the Lancet, June 24, 1871,
may illustrate this point. When he was Pathological Registrar at King's
College Hospital he was constantly exposed to the various contagious fevers,
and, at post-mortem examinations, to the poisonous fluids of dead bodies, yet
as long as he remained at his post he escaped all infection although his
general health broke-down from over work. But on his return, strong and
well, from a holiday in the pure air of the coast, he had so lost this immunity
that he was immediately attacked with scarlet fever in a severe form, and
also with erysipelatous inflammation of the hand and arm, and mischief in the
axillary lymph-glands, following a scratch on his finger at a post-mortem,
examination.
328 ON DISSECTION-POISONS.
you both patience and hope in your treatment of the
consequences of disease. It makes me beheve that I
might now, with perfect safety, examine any dead body
whatever.
Now let me tell you, with commentaries, what the
virus did in me. The examination was made on February
4, and after it I finished a long day's work, feeling un-
harmed. On the 5th, which was a Sunday, I felt, not
ill, but tired, and I spent the greater part of the day idly,
falling asleep over good books. On the 6th I lectured,
in the morning, on the morbid structures obtained from
the examination, and the theatre was, as usual on Mondays
in the winter, very cold. I was chilled and very tired ;
but a heavy day's work had to be done, and I did it. I
had observed three or four small pustules on my hands,
especially one on the back of my left hand, but they
caused no discomfort, and I had no suspicion of being
hurt till about five o'clock, when I felt my left axillary
glands tender, and could not press my arm against my
side. At half-past eight, when I got home, I was cold
and ill ; the mischief had begun.
I mention these things that I may illustrate, as I have
often before done, the influence of fatigue in developing
disease, or in at least making one susceptible of it. I
can be as sure as of anything whicli has not occurred,
that if I could have rested for two or three days after the
insertion of the virus, it would have done me little or no
harm. I cannot tell you whether it is by mere diminution
of a normal power of resisting changes, or (as Dr.
Carpenter has shown to be more probable) by the pro-
duction in the fatigued organs of some material on which
FIRST EFFECTS. 329
morbid poisons may multiply or flourish ; but you will
find in every day's practice that fatigue has a larger share
in the promotion or permission of disease than any other
single casual condition you can name.
Thus, then, I was prepared for receiving injury, and
the injury was supplied in some material of this dead
body. And I repeat that this material was probably
something special enough to be called a virus or poison ;
for although any decomposing organic matter may in
some persons give rise to the worst forms of blood-poison-
ing, yet I have no reason to think they would have done
so in me. Not a day had passed for many months with-
out my hands being in contact with pus and other
decaying or decomposing organic matters ; yet none of
these poisoned me, though I was often as much fatigued
as when I fell ill.
I wish that I could tell exactly all the signs of illness
that I so anxiously watched ; but during acute disease
one cannot record, and after recovery one cannot well
remember, the daily progress of a case. I can only tell
the general consequences of this poisoning.
The first thing observed was a few small pustules on
the hands, very trivial-looking things, which appeared on
the day after the examination, and in the next week or
ten days dried without discharging or causing any local
trouble. I think they were only local effects of the
simply irritant fluids of the body, or of the carbolic acid
oil, with which I had uselessly though thoroughly rubbed
my hands before beginning my part of the examination.
I see no reason for supposing that the material which
poisoned me was from any of these pustules.
330 ON DISSECTION-POISONS.
The first sign of the general poisoning was (as I have
said) the pain in the axillary lymph-glands. No lymph-
vessels could be seen or felt up the arm at any time ; the
absorbed material traversed them, but did not irritate
them : but the glands enlarged, and became painful to a
degree far surpassing the swelhng or any other sign of
inflammation iii them. I do not know whether this ex-
ceeding painfulness was due to something in the poison,
or was dependent on some peculiarity in my nervous
system. I have seen it in one other case of poisoned
wound, in which, as in mine, it indicated no great severity
of inflammation in the glands. With me it slowly
diminished, but did not quite cease till I was nearly well
again, although no considerable morbid changes took
place in the glands. They were large and painful ; nothing
else.
Next after this affection of the axillary lymph- glands
came widespread inflammation of cellular tissue. But
before saying more of this I ought to tell what may have
had some influence in determining the course of my case —
namely, that my axillary glands were already damaged,
and may have been less penetrable by fluid than they
should be. More than thirty years ago, when I was a
student, I had an irritable large pustule on a finger, due,
I think, to some irritation in dissection, and this was
slowly followed by suppuration of my left axillary glands.
After discharging for many weeks, it healed with \ deep
scar and shrivelling and partial calcification. Thus
damaged they may have too much hindered the course
of the absorbed fhiid ; but I doubt their doing so, for I
have never been conscious of any obstruction in them ;
CELLULAR INFLAMMATION. 331
and in other cases of patients with healthy lymph-glands
the same inflammation of cellular tissue as I had occurs.
This inflammation, which became evident four or five
days after the infection, extended quickly from the axilla
up the left side of the neck, over and below the clavicle,
and down the back nearly as far as the ilium. Observe
the range within which the inflammation was limited, for
in this, as in other cases, it was in the range of lymphatics
directly, or not far from directly, connected with the
lymph-glands first affected. A frequent site for such
cellular inflammation is down the side of the chest, or
over or beneath the pectoral muscles. Thus it was with
Mr. Bloxam, who was poisoned about a fortnight after
me, and in whom acute pleurisy with effiision occurred
on the same side. But, so far as I know, cases do not
occur of similar inflammation on the opposite side, or
separated far from the lymph-glands corresponding with
the poisoned part, unless it be at a later period of illness,
when pyaemia is established. This seems to be a point of
distinction between these dissection-poisonings and
pygemia ; their effects are at first, however severe, com-
paratively limited to the part poisoned, and to the
lymphatic vessels and glands, or to the cellular tissue,
nearly in relation with it. They may lead to pyasmia,
but they do this only by secondary changes, or, as it
were, by some accident.
The range of cellular inflammations in these cases,
following, as they do, on the affection of the axillary
glands, seems to indicate that they are due to arrest of
lymph in the affected parts, and to its being poisoned by
reflux from the glands. Thus poisoned it would at once
332 ON DISSECTION-POISONS.
infect the cellular tissue in contact or close proximity,
and hence would be derived the spreading inflammation,
much like phlegmonous erysipelas, with sloughing or dif-
fuse suppuration.
In my case the inflammation, at first Avidely diffused,
gradually concentrated its effects in two places — first at
the back, nearly over the angle of the sixth rib, where
suppuration was evident about a fortnight after the first
appearance of the swelhng, and, about a week later,
under the edge of the trapezius, just above the level of
the clavicle. Both these abscesses were freely opened.
The first was seated in the deepest part of the subcuta-
neous cellular tissue, and the second under the cervical
fascia. The first suppurated very freely ; the second
scantily. Both healed soundly in five or six weeks from
the time of opening them.
The position of this second abscess deserves notice, for
it was probably due in part to the old damage of the
axillary glands, of which I have already spoken. It w^as
such an abscess as might have pointed in the axilla, and
I always felt as if it would do so, for hardness and pain
could always be detected there. But it seemed as if the
axillary tissues would not yield, and therefore the abscess
extended upwards, above the apex of the axilla, to the
vsubfascial tissue beneath the edge of the trapezius. Both
these abscesses were opened early — that is, so soon as
fluid was clearly discovered in them. And I felt the
comfort and utility of this practice ; for though they had
given me very little pain, and had been soothed with
j)0ultices, yet they seemed to keep alive my fever, and
especially before the pointing of the second I had chills
ABSCESSES. 333
and exhaustion, which were evidently remedied by its
being opened. In the opening I enjoyed the safety Avhich
I have often conferred on others by the adoption of Mr.
Hilton's plan. The abscess lay very deep, and was very
small, under the edge of the trapezius, and with integu-
ments and cellular tissue so thickened over it that all the
landmarks for incisions were lost, and the district was one
in the depths of which a knife, however skilfully used,
might have given me serious trouble. The director
penetrated the abscess safely, and the forceps sufficiently
dilated the opening, and I had self-evidence on which to
urge you to use Mr. Hilton's plan in all operations on
abscesses in dangerous regions.
After the opening of the abscesses the infiltration of
the cellular tissue about them cleared up slowly, very
slowly ; and, more than once, patches of thick oedema
appeared over the left ilium as if suppuration would take
place there ; and when erysipelas came on there was
much more than usual oedema with it, as if there were
still some hindrance to the free movement of the lymph.
The general illness that attended these suppurations
was not severe. When it was evident that abscess would
form — that is, a fortnight after infection, — I was sent to
Norwood, and, with the fresh air and quiet of the place,
I gained strength, and cfould eat and drink well, and
digest pretty well, and seemed floating into convalescence.
But just before the evident suppuration of the second
abscess, I had chills every day, and after them heat ; and
with these great loss of power and general distress —
distress so keen that it seems strange that I should now
be unable to describe it, or even clearly to remember it.
334 ON DISSECTION-POISONS.
This general illness, this constitutional disturbance,
was, I believe, the beginning of erysipelas. But before
speaking of this, let me tell that the pus from my abscess
appeared to have more irritant properties than ordinary
pus. For my childrens' nurse, who made and changed my
poultices, pricked her finger ; and this was followed by
very acute inflammation and suppuration, extending from
the puncture over all the hand and forearm. The
same thing happened, through a similar accident, to Mr.
Bloxam's nurse, one who was habituated to pus of all
ordinary kinds, and had not suffered from it.
Of the erysipelas that affected me after these abscesses,
beginning about a month from the time of infection, I
need not say much ; for it had no remarkable feature,
unless it were in the degree of subcutaneous oedema which
predominated over the inflammation of the skin and re-
mained very long. Beginning near the wound in the
neck, the erysipelas spread slowly over the chest and
back, down the left arm, and over parts of the thighs.
The eruption was much more extensive on the left side
than on the right ; it slowly cleared-up, and after de-
squamation no trace of it remained, unless it were in a iveak-
ness of the minute blood-vessels of my arm ; for after
my bath, for many weeks the affected part of this arm
appeared dusky and mottled.
It was during the erj^sipelas that my general health
suffered most ; but my recollection is not clear about any-
thing but the feelings of intolerable restlessness, which
nothing but wine or morphia would tranquilise, and of
the interest with which for many days I watched the pro-
gress c)f my own case, fancying myself an intelligent
ER YS IP EL AS, TREA TMENT. 335
observer. At last, after the erysipelas had been extending
for about ten days, and at the end of nearly six weeks
from the infection, there came what seemed to me like a
crisis. Daring the night in which my pulse and tempera-
ture were at their highest I had a profuse sweating and a
profuse flow of urine, such as I never had in my life
before ; and next day my pulse and temperature had
come down to what might be deemed safety-points, and I
was conscious of returning health.
In the treatment that I received during the erysipelas,
I am sure that quinine was very useful. I generally took
three or four grains of the hydrochlorate three times a
day, and it always (I think) lowered my pulse, and dimin-
ished my restlessness and (I believe) my temperature.
And I wish I could tell the comfort that morphia gave
me — whether in bringing sleep, or in changing the unrest
that always increased towards night into a happy and
complacent wakefulness almost as refreshing as sleep. It
was well that pleasure unnaturally obtained should have
a penalty ; and this was in the dryness of mouth, which
seemed due to a total suspension of the secretion of saliva,
and which became at last even less tolerable than restless-
ness. Locally, collodion, freely applied as soon as an
erysipelatous redness appeared, gave great comfort. It
did not hinder the spreading of the erysipelas ; but it
relieved the itching and heat of the eruption, and it pre-
vented the horrid itching of the desquamation, which was
intense, and was renewed for many days on exposure to air,
at every place to which the collodion was not applied.
These things were certainly beneficial ; but I suppose that
those which most helped me to a safe passage through the
336 ON DISSECTION-POISONS.
illness were, a judicious moderate use of food and wine,
and very wise and gentle nursing.
This erysipelas, it may be believed, was part of the
effects of the poison of the dead body — an issue of the
blood-poisoning. Not such, I think, was a pneumonia
with which I suffered twice, and which added greatly to
the risk and length of my illness. This was, probably,
personal ; due only indirectly, if at all, to the poison — due
rather to a susceptibility of my lungs to the inflammatory
process. For I had had acute pneumonia five times
during the eighteen years before this illness. All these
attacks occurred after severe over-work, with de-
ficient food and exposure to cold ; and the manner in
which they have cleared-off, leaving my lungs unimpaired
in structure, has made it nearly certain that they were
rheumatic or gouty. But, however this may be, the
pneumonia, of which one attack commenced only two
days after the infection, and the other a week after the
disappearance of the erysipelas, must be ascribed to me
rather than to the poison. They passed through their
usual course, and left my lungs sound again ; but I ask
your attention to them as an illustraftion of one of the
ways in which a specific disease may be complicated or
modified by the personal constitution of the patient.
Here was an instance of what one may call a specific
poisoning ; and one of the first tilings following it was
pneumonia. Associated as this was witli evidence of
poison in the lymph-glands, it might have been thought
pyaemial, or in some way due to the specific poison in the
blood. Yet it was only such a pneumonia as I might
PERSONAL SYMPTOMS. 337
have had without having been poisoned, or such as might
occur in me in any feverish ilhiess from whatever source.
Keep such facts as this in mind. They show that
there is no disease so specific but that its signs may be
confused or comphcated with the things that are pecuhar
to the patient. Syphihs is a specific disease as sharply
defined as any, but its course and appearance in a scrofu-
lous man and in a gouty one are very different. Vaccina-
tion produces a well-marked specific disease ; but in one
patient it may be followed by inflammation of lymphatics,
in another by eczema, in others by various other troubles :
but all these are due in only a minor degree to the vacci-
nation ; they come out from the personal constitutions of
the several patients which are disturbed by the vaccina-
tion, as they might have been by anything else producing
some slight fever.
This is not a mere question of doctrinal pathology.
It is among the first necessities for success in practice
that, in the total phenomena of a disease observed in any
patient, you should be able to estimate what belongs to
the disease and what to the man. A farmer may as well
expect success if he sows his fields without regard to their
soils or to the weeds that may ' of themselves ' come up in
them, as one of us may expect it if we treat diseases with-
out exactly studying the constitutions of those in whom
they occur.
Thus I have given a sketch of my three months' ill-
ness, and some of the thoughts which it suggested to me.
But I ought to say that my case showed only one of
many forms of disease that may be produced by tlie
poisons of dead bodies. The suppuration of lymph-glands,
z
338 DISSECTIOX-POISOXS.
which I had many years ago, is anotlier. But besides
such as these, you may find cases of trivial local inflam-
mation ; of direct and simple erysipelas ; of spreading,
suppurating, or sloughing inflammation of the cellular
tissue of the hand and arm ; of pyaemia ; and of the
fiercest septica3mia. And it is remarkable that different
effects may be produced by the same poison acting on
different persons. Mr. Erichsen mentions a case in which
six students were infected by the same body ; ' two had
suppuration of the areolar tissue under the pectoral
muscles and in tlie axilla ; one was seized with a kind of
maniacal delirium ; a fourth had typhoid fever ; and the
other two were seriously though not dangerously indis-
posed.' I advise you to read-up the subject in his ' Art
and Science of Surgery.' ^ He has given an excellent
account of it ; and so has Billrotli in his and v. Pitha's
* Ilandbuch der Cliirurgie.' ^
Sir William Lawrence used to say that he had not
known any one lecover on whose case more than seven had
consulted. Our art has improved. I Iiad the happiness of
being attended by ten : Sir Thomas Watson, Dr. Burrows,
Sir Wilham Jenner, Dr. Gull, Dr. Andrew, Dr. Gee, Mr.
Caesar Hawkins, Mr. Savory, Mr. Thomas Smith, and Mr.
Karkeek. In this multitude of coinisellors was safety.
Tlie gratitude I owe to them is more than I can tell —
more than all the evidences of my esteem can ever prove.
^ Vol. i. p. 151, ntli edit. 18G0.
2 Bd. i. Abth. ii. Ilcft. ii. p. 70; Erlangen 18G7.
539
QUIET NECROSIS.
The ordinary phenomena attending and following necrosis
■arc well-known and described : the inflammation of all
the textures about the dead bone, inflammation attaining
an extreme intensity, spreading far, leading to suppura-
tion, and attended with fever as acute as itself. In the
midst of local inflammation, and with general feverish
disturbance, the exfohation of tlie dead bone begins, and
usually suppuration continues till tlie exfoliation is com-
plete and the dead piece is removed.
But all the essential parts of the process of necrosis,
the death of the bone and its exfoliation, and the forma-
tion of new bone, may take place without any of the
attendant phenomena of either inflammation, or fever ;
and tlie cases in which this happens, the cases of ' quiet
necrosis ' as I would call theiu, are of great interest in
both pathology and diagnosis.
My attention was first fixed on these facts by a case
wliich I communicated to the Clinical Society, and wliicli
is published in the Society's 'Transactions,' vol. iii. p. 183.
Emma L aged 19, a general servant, was admitted
into St. Bartholomew's Hospital under my care, on October 12,
1869. tSlie was well nourished, and muscular, and, except in
z 2
340 QUIET NECROSIS.
being rather pale, looked healtliy. Her complaint was of severe
pain in the left knee, for which she had been under treatment
for a month. Her mother died of heart-disease, her father was
rheumatic, she herself had been healthy till this pain in the
knee set-in.
The knee-joint was very slightly swollen, with fluid in its
cavity, but not hot or tender. What seemed more important
was that a hard swelling of which the patient knew nothing^
nearly surrounded the middle of the shaft of the femur. This-
swelling felt of nearly oval form, about six inches in length ;
it was in every part very firm, and tense ; hard pressure on it
was very painful, especially at its middle part. All the textures
of the thigh appeared quite healthy ; no part of it felt hotter
than another ; no veins or lymph-glands were enlarged. The
pulse was rather quick ; but the breathing and temperature-
appeared natural ; there were no signs of fever or general dis-
turbance, and, but for the pain of her knee, the patient would
have thought herself well. She could give no account of the
swelling round the femur, except that it might be due to her
frequently breaking thick pieces of wood across her thigh.
in the belief that the swelling round tlie femur was due to
periostitis, the patient was directed to remain always in bed,
to take three grains of iodide of potassium three times a day,
and meat diet ; blisters also were to be applied over tlie swelling'
often enough to maintain a constant slight inflammation of the
skin.
At first some benefit seemed to be derived from tlie treat-
ment ; the swelling became rather less, and was not so tender
on pressure, l^ut the improvement was of short duration, and
on December 2, the doses of iodide of potassium were increased to
six grains, and a fortnight later to nine grains, three times a
day. On each of these occasions the pain and swelling were
for a few days diminished ; but no real advantage was gained,
and after being inider treatment for three months the condition
of the afl'ected parts was almost exactly the same as when the
patient was admitted. The pain in the knee had continued
with very little change, l)ut the swelling of the joint had sub-
QUIET NECROSIS, 341
sided. The general health also remained unaffected ; during
the whole of the three months she had not a chill, or a great
heat or thirst or loss of appetite. . . .
In consultation it was decided that the periosteum at the
seat of disease should be cut through. For it seemed nearly-
certain that the case was one of periostitis maintained by some
confined source of irritation — pus, or ulcerated bone, or the like.
It might be a low bony growth covered with inflamed perios-
teum, or with an inflamed bursa, or it might be a cancerous
tumour ; but this seemed too improbable for an objection
against the proposed treatment.
On January 13, I made an incision about six inches long,
in the outer part of the thigh, over the principal and tenderest
part of the swelling. All the textures cut through down to the
outer surface of the periosteum appeared perfectly healthy;
there was not in any of them the slightest sign of inflam-
matory change. The periosteum was, in the portion divided,
from one-third to one-half of an inch thick, and in all its
thickness dense, tough, white, and moderately vascular.
Between the periosteum and the bone, the incision laid open a
flattened irregular cavity, from which a little blood-coloured
fluid escaped, and was followed by the protrusion of some soft
substance like coarse granulations. In tliis cavity, which was
from an inch to an inch and a half in its diameters, was a thin
rough sequestrum, separated from the wall of the femur, about
an inch and a quarter long and a quarter of an inch wide.
The walls of the cavity, of which the outer was formed by the
thickened periosteum, and the inner by the hoUowed-out
surface of the femur, felt smooth and velvety as if covered with
gTanulations like those of ordinary cavities containing sequestra.*
The sequestrum appeared to be derived, not from the
outermost layers of the femur, but from layers just within
them.
In another case a boy, 13 years old was under my care in
^ The condition was very similar to that of a cavity with ' subcutaneous
granulations ' in a case of ununited fracture. * Lectures on Surgical Patho-
logy ' iird Ed. p. loo.
342 QUIET NECROSIS.
St. Bartholomew's, with a hirge ovoid swelling round the-
upper part of the left humerus, which had slowly and painfully
increased for about a year. It was thought most likely to be a
firm medullary cancerous growth, but the doubts were enough
to justify an exploratory incision. This was made through
perfectly healthy textures till the periosteum was reached,
which was greatly thickened, and covered some cavities con-
taining thickened and half-dried pus, and several small
sequestra from the wall of the humerus.
The condition found in these two cases is illustrated
on a large scale by a specimen in the museum of the
hospital.-^
In the right femur and the left tibia of the same person,,
large portions of the inner layers of the walls of the shafts are
completely separated after necrosis ; but, in the thickened outer
layers surrounding the sequestra, there are no openings for the
discharge of pus. ' Under these circumstances,' as Mr. Stanley
observes,^ ' it is not to be expected that abscess and fistulous
passages would form in the soft parts adjacent to the bones.'
A similar and ver}' renunrkable instance of necrosis of
the shaft of the femur without suppuration occurred in
the hospital last year, under the care of Mr. Baker, and
will, I hope, be soon published by liim.
All these cases are sulficient to prove that, however
rarely, the whole of the customary processes of necrosis,
short of the extrusion of the dead bone, may be accom-
plished quietly without evidences of inflammation. By a
similar process we may ex])lain the formation of some of
the loose bodies in joints. Of these bodies there are two
chief kinds. Some are abnormal out-growths of cartilages,
' ^iMuseum Cat.' vol. i., Subft-rics A, No 118, l]l).
2 ' Diseases of the Boues/ 181!), p. 79.
QUIET NECROSIS. . 343
formed in chronic rlieumatic arthritis, or in the dendritic
growths of synovial fringes, and, as it were, accidentally
detached. Others are portions of the proper articnlar
cartilage, with or withont some snbjacent bone, which
have suffered a ' quiet necrosis,' and been exfoliated into
the cavity of the joint.
Mr. Teale ^ described this process of necrosis of carti-
lage. Being ignorant of his paper I published a similar
account of the process in the ' Hospital Eeports,' '^ adding
to Mr. Teale's account only the fact that the microscopic
structure of these loose bodies is identical with that of
articular cartilao'c.'^
I am unable to explain the conditions under wdiich a
process of necrosis thus widely dissimilar from that which
is usual takes place. I suspect that the death of the piece
of bone or cartilage is always due to violence, that the
piece is killed, as a tooth may be, by a blow, and that as
a tooth thus killed may be ejected or exfoliated quietly,
Avithout cliange of structure or any signs of destructive
inflammation about it, so may the piece of bone or car-
tilage. But the facts yet known are too few to be sure on
this point ; and so, in the question of diagnosis, there are
no distinctive signs of a quiet necrosis, but the chance of
its existing should be kept in mind in all obscure cases of
swelling on a bone.
1 <Med. Chir. Trans.' vol. xxxix, p. 31.
3 Vol. vi.
^ Some illustrative specimens are in the Museum of the Hospital (Ser. ii.
84, and Ser. xxxv. 55) and are described by the Editor in the 'Keports,'
1868.
344 SENILE SCROFULA.
SENILE SCROFULA.
It is, I think, too often taken for granted that scrofula is
almost exclusively a disease of the earlier part of life.-'-
Doubtless, young persons are much more often the sub-
jects of scrofula than are those of later j^ears; but the
old, i.e. people over 60, are, I believe, more often scro-
fulous than those between 30 and 50, and certainly are
more often so than they are generally supposed to be.
The evidences of scrofula in the old are not only in
certain diseases of internal organs to which a scrofulous
origin may be probably assigned, but in the diseases of
lymph-glands, bones, joints,- the spine, tlie testicles, and
otlier structures which appear to be the ' seats of election '
of scrofula in the young. Tliere is not one of these struc-
tures in whicli I have not seen, within the last few years,
instances of scrofulous disease in people more than GO
years old. The cases appear equally frequent in private
and in hospital-practice, and no period of hfe is too far
advanced for tliem ; some of the most marked have been
in patients above 75 : one of tliem was in a patient 91 years
old.
' The same error is in many minds respecting plitliisis, even tboui^h
many clear accounts of phthisis in the aged liave beeu written.
"" Note XVI.
SENILE SCROELEA. 345
The characters of scrofula in the old are, essentially,
the same as in the young. I cannot, indeed, describe any
striking peculiarities of form or features by which the
scrofulous old persons may be recognised ; but they are
generally of weakly health, ready for disease, susceptible
of it under comparatively slight provocation. They tell
of weakly relatives, or of consumption in their families ;
or of their having been subject to marked scrofulous
affections in early life, and of having survived a time
of great delicacy of health, and then passed into a com-
paratively healthy middle age.
In its local features, also, senile scrofula agrees with
that of early life, or differs only in its yet greater slow-
ness and the more thorough degeneracy of the affected
parts. The same slov/ softening of textures ensues ; the
same slow ulceration and slower healing, with pus con-
taining granule-masses and granules rather than well-
formed pus-cells.
But notwithstanding its likeness to so well-known a
disease as the scrofula of young persons, the senile scrofula
is sometimes difficult of diagnosis. In superficial parts,
the skin and mucous membranes, the difficulty is usually
between scrofulous affections and gouty. Between these,
I believe that the diagnosis must be ensured by observing
the co-existing constitutional characters, or other marks
of disease. But this is often difficult : for gout and
scrofula are often, by inheritance, so intermixed that the
resulting condition can hardly be analysed.
In deeper-seated parts, as the lymph-glands, bones,
and joints, the difficulty of diagnosis is more frequently
between scrofula and cancer. In the young this difficulty
346 SENILE SCROFULA.
seldom occurs : for in tliein cancer is comparatively rare
in the parts in which scrofula is frequent. In the old,
the lymph-glands and the bones are as frequently the
seats of scrofula as of primary cancer. In the old, there-
fore, the difficulty of diagnosis between these two diseases
may be greater and more frequent than in the young ;
but I tliink that the difficulty is commonly due, in some
measure, to our expecting to find cancer rather than
scrofula in old persons. The regularly increasing fre-
quency of cancer as age advances, i.e. its increasing fre-
quency in proportion to the number of persons living at
each advancinc^ ag;e, is well known : and this knowlednre
gives some prejudice in favour of believing that a swelhng
in an old person is very likely to be cancerous. Scrofula,
on the other liand, is often presumed to be very unhkely.
I believe that if it were generally admitted to be not very
unlikely, the difficulty or hesitation in making out its
existence would nearly cease.
Some general rules for the diagnosis, liowever, may
be kept in mind.
In the cases of doubtful diseases of tlie bones or of
doubtful swellings not glandular, the scrofulous affections
are generally inflamed, however lowly ; the cancerous are
not so. Tenderness and heat are indications of scrofula
rather than of cancer, and are rarely absent at and about
a scrofulous bone at whatever time of life ; with cancer
they are present only when the diseased part is casually
inflamed.
Spontaneous pain — that is, pain indopcMident of move-
ment or pressure — indicates, if severe, cancer ratlier than
SENILE SCROFULA. 347
scrofula ; but it is a very fallacious sign, especially in the
early periods of eitlier disease.
Eedness over diseased bones tells of scrofula more
than of cancer. When present with scrofulous disease in
the old it is duskier and less ruddy than in the young ;
not only because of the less brightness and probably
slower movement of the old blood, but because of the
deeper colour of the epidermis, which, with its brown
pigmental degeneration, partially veils and shades the
colom' of the blood beneath it.
In the diagnosis between scrofulous and primary can-
cerous lymph-glands in the old, the chief things indicative
of cancer are hardness or at least great firmness of sub-
stance, close-clustering, deep-seated attachments, pain, and
quick increase. The opposites of these conditions, especially
when tenderness and external redness are added to them,
commonly signify scrofula. In the cervical lymph-glands,,
which, in old persons, are the most frequent seats of both
scrofula and cancer, the lower glands are most frequently
scrofulous, the upper ones cancerous ; the soft primary
cancerous disease is very rare in the old, and not so rare
in the young ; the soft scrofulous disea'se or simple hyper-
trophy which is frequent in the young is very rare in the
old ; the cancerous disease in the old is often secondary
to some comparatively trivial primary disease ; the scro-
fulous is very rarely so.
Eespecting the treatment of senile scrofula little need
be said. I believe that whatever is useful for scrofula in
the young is, not indeed useless, but less useful in the old.
As age advances, all medicines that act by increasing the-
activity of organic processes become, as it seems, less-
348 SENILE SCROFULA,
potent : and so iron and cod-liver-oil and iodine have
comparatively little influence. Even high mountain-air
and sea-air become, as age advances, less invigorating,
and the more so the more the old age is attended witli
infirmities that hinder active exercise.
349
SCARLET FEVER AFTER OPERATIONS.
The boy lately operatecl-on for stone had scarlatina ; at
least, an eruption exactly like that of scarlatina appeared
over nearly the whole surface on the day after operation
with general febrile disturbance. Two days later it
began to fade, and in a few days had disappeared, and
left him in about the same state that we may suppose he
would have been in if no such illness had occurred ; all
went on well for a month, the wound Avas nearly healed,
and he was deemed convalescent, when perhaps in con-
sequence of exposure to cold, he had severe pain in
passing urine, and evacuated with it a considerable
quantity of blood from the kidneys, and tenacious mucus.
Two days after this he had sore- throat, then an eruption
like scarlet fever again appeared : it continued for three
days, and was succeeded by desquamation. The urine in
about ten days had gradually regained its natural condi-
tion, and he again seemed well. But now whooping-
cough set in, and again retarded, though it did not finally
prevent, recovery.
If I had never seen a case similar to this I should
have hesitated to call it scarlatina ; for the symptoms of
the first attack were very incomplete, and tliosc of the
350 SCARLET FEVER AFTER OPERATIONS.
second were imusual and disorderly. But I believe the
case was really one of scarlatina modified by the circum-
stances in wliich it occurred : and that it may be reckoned
witli other similar cases in illustration of some interesting
general principles.
About this time last year, when scarlatina was yery
prevalent, I saw six ceases after operations in private
practice, I have notes of four more tliat occurred either
before or since, and I have heard of many more. By
some, these cases may ])e su])posed to liave been only
casual coincidences of scarlathia with surgical diseases ;
but if they were so, we ought to find a ])roportionate
mnnber of cases among surgical cases not operated-on.
But this does not liap])en. In private practice I do not
remember to have seen scarlet fever supervene in any
surgical cases, except those hi wliicli o])erations had been
])erformed ; and in Hospital-practice, I doubt whether it
is much more frequent among all the otlier ])aticnts taken
together than it is in those wlio liavc been o]:)erated-on.
I cannot, tlierefore, doubt that there is something in the
i'onsequences of surgical operations wliich makes the
patients pecuharly susce])tib]e of llic iuiluence of the
scarlatina-])oison. And, togetlier willi tliis susceptibility,
we may observe llial the disease undergoes in them
certain niodilicatioiis, especially in the period of incubation,
wliicji is much shortened. In all the ten cases that I
liave noted, the eruj)ti()n a])])(\ire(l within a. wcH^k after the
ojxTation, and in eight of them within three days after it,
nanielv in two cases on tlie first^ in three in the second,
iind in three on the third day.' Other deviations from
» Note Xyil.
SCARLET FEVER AFTER OPERATIONS. 351
the t}^)ical course of scarlatina were that, in some of the
cases, the eruption came-out over the whole surface at
once, and on the limbs more fully than on tlie face and
chest ; in some there was no sore-throat ; in otliers no
desquamation.
Tlie cases are not numerous enough to determine the
import of these various deviations from the t}^)e of
scarlatina, but that in which all of them, whether complete
or incomplete in other characters, agreed, namely, the
very early period after the operation at which the rash
appeared deserves particular notice. It adds to the
evidence that the appearance of scarlatina is in some way
<:^onnected with the early consequences of operations. If
it were not so, there would be no reason wliy the
eruption should appear early, rather than late, after the
operation ; but, so far as I have seen, it always appears
early, always within the first week.
Two explanations may be offered of this fact. Either
the condition induced in a patient by a surgical o]3eration
is one that gives a peculiar liability to the reception of an
epidemic or contagious morbid poison, and any one of
these, being imbibed immediately after the ojoeration,
produces its specific effect in much less than the usual
])eriod of incubation : or else those who suffer witJi
scarlatina within a few days after operations had previously
imbibed the poison, but would not have manifested its
effects so soon, if at all, unless their health had been ex-
hausted or disturbed. The second of these explanations
4i])pears rather the more probable ; for it is in accordance
with what has been observed when many persons have
352 SCARLET FEJER AFTER OPERATIOXS.
been exposed to the contagion of fever and some have
been afterwards exliansted by fatigue or otherwise. These
have liad fever ; while those who rested after exposure
have escaped it.
But, whatever cx])lanation may be given, the fact of
the pecuUar Hability to scarlatina after operations seems
certain, and may l)e important in relation both to the
pathology of the disease and to the risks of surger}'.
In one of the cases which I have seen it Wiis fatal ; in
another it was followed by fatal pyaemia : and I think it
not improbable that, in some cases, deaths occurring with
obscure s^inptoms, witliin two or three days after opera-
tions, have been due to the scarlet fever-poison hindered
in some way from its usual progress.
353
NOTES FOE THE STUDY
OF SOME
CONSTITUTIONAL DISEASES.
I OFTEN wished to give some clinical lectures on constitutional
diseases, especially on those which are inherited, and through
inheritance subject to many and wide variations from what are
regarded as their typical forms. These notes are the collected
fragments and failures of many attempts so to express what I be-
lieve on parts of the subject that it might be possible for students
to listen to me for an hour at a time. I convinced myself of my
inability to teach the subject orally ; and I am doubtful whether
I have written anything worth reading.
The study is beset with much greater difficulties than, at
first thought, appear. The sufficient materials for it exist only
among patients whose health can be observed through many
years, and whose family-histories can belearned. Of such patients,
a sufficient number and variety can be found only in some
large general practice among tlie richer classes of society : but
the few who attain such a practice soon find that its duties are
too laborious to allow time for any careful record of the facts
they learn. In the incomplete study of the subject in sur-
gical practice one can. gain only very incomplete knowledge ;
but since what I have gained may not be all inaccurate, or all
useless, I venture to publish some of what I believe to be true.
The knowledge of the chief inherited constitutional
diseases, as of gout, tuberculosis, scrofula, in wliat may be
regarded as then- typical and complete forms, is nearly as
A A
354 STUDY OF CONSTITUTIONAL DISEASES.
good as any yet attained in pathology. But it is far
different with the study of these and other less marked
constitutional diseases in the more numerous instances in
which they exist in less complete forms, or are mingled
and confused with one another, or with the effects of
injuries and accidental diseases. In reference to all these
the facts are, for the most part, so vague and undefined,
so confused and apparently inconstant, that it has often
seemed to me useless to pursue them. But, more often,
I have felt sure that there is great value in the study of
even the least signs of constitutional disease : and that,
although we may never attain to a scientific precision or
completeness of knowledge in the matter, we may, with
care, gain a large quantity of information which may help
to right diaoiiosis and ri2;ht treatment of diseases.
If this seems doubtful, consider the success witli
which a somewhat similar study is pursued.
Each man's constitution is to be studied in the wliole
character of his health, both bad and good ; in tlie same
sense as that in which character is studied in relation to
any one's mental or moral condition. And we may
observe a parallel between tlie study of constitutions in
men's liealth-characters, and tli at of their minds in mental
or social characters. Eacli man's mental character is derived
by inheritance, througli we know not liow many genera-
tions, or witli wliat variations and confusions : and in
each man tliis natural character is susceptible of modifi-
cation, not only by education and all the circumstances
of life, but by that which may be the strongest of its
components, self-will.
I suppose that, if wo could count the elements of
STUDIES OF CHARACTER. 355
which minds are constituted, they would l)e at least as
numerous as those that make up the constitutions of our
bodies. The minds derived from their combinations are so
numerous and so various that they do not admit of any
precision of classes or names. Yet, a practical know-
ledge of them may be gained with singular exactness.
There are men who are, as it is said, excellent judges of
character. With observation of demeanour, of expres-
sion and of occasional conduct, and perhaps some study
of each man's history in life, or of his descent and family-
relations, they can ascertain the most important features
of the mental character of nearly every one who comes
before them. They can hardly tell how they do it ; they
cannot make a science of their knowledge ; and yet for
practical life they commonly surpass those who can write
excellent essays on the human mind. They learn the
general character, or the most prominent and influential
part, of each man's mind ; what chiefly guides his conduct :
what in him may be most easily acted on ; and witli this
knowledge they make their diagnosis and guide their
practice.
Similarly, and with more care and labour, have we to
study constitutions in the personal health-characters of all
our patients ; not only of those whose unhealthy consti-
tutions are signalised in some typical form of disease, but
of those wlio to the unobservant may seem nearly well, or
indefinitely ill, or, at the most, only locally unsound.
And I am sure of this ; that as the justly successful
members of our profession grow older, and ])robabty
wiser, they more and more guide themselves by the study
of their patients' constitutions, learning more of family-
A A 2
356 STUDY OF CONSTITUTIONAL DISEASES.
histories, and detecting constitutional diseases more skil-
fully in signs wliich, to others, seem trivial.
MEAXINGS OF XAMES.
I say meanings rather than definitions, for when know-
ledge is very incomplete we cannot exactly define all the
words that we may use.
By constitutional diseases are generally meant morbid
conditions which affect the whole method of life and
indicate themselves by distinctive local morbid processes.
The inherited constitutional diseases, of which almost
alone I propose to speak, are those in which morbid con-
ditions affecting the wdiole method of life in parents are
reproduced in their offsprings. In some persons the
morbid conditions are evident throughout life in charac-
teristic forms, complexions, peculiar relations to food or
to injuries, or in other signs, such as are seen in well-
marked instances of scrofulous, tuberculous or rachitic
persons. In others, there may be the appearances of
complete health till the morbid constitutional condition
indicates itself in one or more local diseases, in which it i^
then said to be manifested or localised.
Tlie condition preceding tliis local manifestation of
constitutional disease is commonly called a constitutional
tendency or disposition to disease. Diathesis and
(lyscrasia mean nearly the same : and temperament has, I
til ink, ])art of the same meaning ; but this word is
commonly used witli e})ithets so strange tliat I think it
best to avoid it altogetlier.
By constitutional disturbance or disorder is generally
undci'stood a general and pervading disorder of the
DISPOSITIONS TO DISEASE. 357
whole health excited by some local morbid process, such
as that m an uTitated or inflamed wound.
I shall keep to the words with these meanings with-
out professing more than that they are convenient.
CONSTITUTIONAL TENDENCIES OR DISPOSITIONS
TO DISEASE.
These are not to be thought of as unreal or accidental
things. Eather they are progressive changings, growings-
up towards complete and evident disease. Sometimes
the progressive changings are not discernible ; sometimes
they are declared by some of the lesser diseases significant
of morbid constitutions. And it is this method of pro-
gressive changing which is transmitted from parent to ojQT-
sj)ring : for a parent may transmit to children a tendency
to gout, or phthisis, or any other heritable constitutional
disease, long before his or her self has shown any clear
signs of it. A parent may ' die and make no sign,' long
after transmitting to offspring such tendencies, such
methods of organic change, as in them, or some of them,
will surely lead to the development of a disease which
the parent has not displayed.
It is well to be sure of the reality of the progressive
changes by which what we call a constitutional disposition
or tendency becomes what we call a constitutional disease,
and that the two names, like 'boy' and ' man,' mean the
same thing in different stages. For the method of life in
each constitutional disposition must be, at any period,
characteristic, though its distinctive characters may be
beyond our present powers of discernment. In any two
children, for example, or in any two embryos, one a
35^8 STUDY OF CONSTITUTIONAL DISEASES.
product of healthy parents the other of tuberculous
parents, however like they may appear, there must be
even now dissimilarity. In the same measure as they are
now becoming constantly more unlike each other, in.
becoming severally more like their parents, in personal
appearance and mental character, so are they becoming
constantly more unhke each other in their dispositions or
tendencies towards healtli or disease. The future diffe-
rence is not more certain than the present, though it will
be more evident. The future is potentially in the present
state ; in some material quahty not the less sure because
not yet sensible. I say ' not yet,' in the full expectation
that minuter study will bring the knowledge of many
things characteristic of constitutional dispositions whicli
we at present overlook or cannot see.
Moreover, it seems right to hold that the differences
among persons of different constitutions pervade every
part and process of their several lives. As matter of fact,
it cannot be shown that, in every instance of a constitu-
tional disease, even in its complete form, and when it
affects many parts at once, the whole method of life does
deviate, in some distinctive manner, from what may be
regarded as the method of an ideal perfect health. But
this is very probable : and in theory it is well to hold
that in each constitution all things are consistent, and,
therefore all characteristic. Certainly, it seems at least
very probable that, for example, in a gouty person
nothing is and nothing works exactly as in a scrofulous
person, or as in a completely healthy one ; and that the
differences, which wc may hope that some of our succes-
sors will discern, are as characteristic during the time of
DISPOSITIONS TO DISEASE. 359
constitutional disposition as during tlie complete
disease.
Similarly in the cases of constitutions wliicli take their
names from the dominant error of one constituent of the
body, as in the nervous or neurotic, and in the cold-
blooded (so-called), it seems most probable that all the
other constituents are consistent with these, and, if we
could discern them, would be found different from those
in other constitutional diseases.
It seems to me better thus to hold a large, even a
vague, theory of the differences of constitutional con-
ditions, than to narrow our thoughts about them by
holding that, in any case, all which is constitutional is in
the blood, or the nervous system, or any other structure
which, in substance or in influence, pervades a man.
Doubtless, the blood and the nervous system, the con-
nective tissue and the lymphatics, pervading as these do
nearly every part, have very large shares in a constitu-
tion, and defects and diseases in them would so quickly
and so greatly influence the whole, that a disease if it
could be in any one of them might, without serious error,
be spoken of as constitutional. Still, it is not right to
regard any one of these, or all of them together, as the
sole factors of a constitution : for, in some cases, as much
might be said of a single organ. When some disturbance
of the action of the liver or the kidney gives a distinctive
character to every process in the economy, either of these
organs might be thought to determine the whole constitu-
tion. But though the influence of the blood or of the liver
may be everywhere, yet neither blood, nor liver, nor any
thing else is everything : a constituent is not a constitu-
56o STUDY OF CONSTITUTIONAL DISEASES,
tion. A constitution should not be tliouoht of as less
than the sum of all those intrinsic thing's from which a
whole health-character is derived.
VARIATION OF COXSTITUTIOXAL DISEASES IX HEREDITARY
TRANSMISSION.
It seems probable that in embryo-hfe there is, gene-
rally, a tendency to recovery from the morbid conditions
transmitted from parents : a tendency to revert to the
true healthy type of structure and composition. Such a
tendency would be in accordance with the general rule
of tendency to reversion from all variations of specific
characters : and would be part of that tendency to recovery
of health which suggested a vis medicatrix naturce, and
which we may observe throughout life, diminishing as
age increases, yet never quite lost. If such a tendency
to recovery did not exist in great force in the embryo,
'sve sliould have to expect a far more rapid destruction
than we see of famihes and races by such diseases as
cancer, tuberculosis and scrofula. Believing in its exist-
ence we might expect what, on the whole, we generally
see ; namely, that iu transmission an inheritable disease
loses in force, many children escaping altogether, and
many displaying the disease in its less severe and less
typical Ibrms. The tendency to recovery is, we may be-
lieve, the greater when one of the ])arents of the embryo is
healthy, so that the constitutional disease of the other may
be, in a manner, diluted. Through such dilutions and
such tendencies towards recovery of liealth in embryo-
life, and in a less degree after birth, we may believe that
many of the lesser constitutional diseas(3s are derived;
VARIATION IN HEREDITARY TRANSMISSION. 361
but of tlie rate of diminution in transmission, and of tlie
possible changes of form associated witli changes of
intensity or quantity of disease, we know very httle, if
anything. And very httle we know of the results of the
transmission of more than one constitutional disease to
the same offspring. But we can often see plainly that
the forms in which different persons display a constitu-
tional /disease appear very different from those seen in
their parents. Thus, in a family of which one or both
parents had typical gout or tuberculosis or scrofula, there
•may appear any number of the lesser forms of those
diseases, or of the forms deviating furthest from the type.
And yet a certain general similarity may appear in all the
local manifestations of each constitutional disease thus
variously transmitted. They may be unlike in structural
appearance while affecting different structures ; and yet
they may be like in their time-work, or in the production
of some characteristic morbid product, or in the influence
which medicines or diets exercise on them. These things
may prove the same constitutional origin in apparently
very different local diseases.
It may be observed, for a safe rule in pathology, that,
when any heritable disease appears in different organs or
textures in different members of the same family, it is
probably constitutional. Tlie rule is illustrated in most
gouty, scrofulous, and syphilitic families, and is available
in evidence of the constitutional nature of cancer : for
cancer, when it happens in many members of a family, is
not tied, as eacli other morbid growth is, to one part or
texture.^
^ Lectures on Surgical Prtthology Ed. '). p. 794-5. Trans, of the Patho-
logical Society Vol. xxv. p. 319.
-.62 STUDY OF CONSTITUTIONAL DISEASES,
EVOLUTIOX OF DISEASES.
The study of the variation of constitutional diseases in
hereditary transmission may lead to knowledge on a
subject of singular interest, — the evolution of diseases.
We are ready to speak as if we believed that the heritable
diseases in our pathology were always such as they are
now. But there is no sufficient historic evidence for this
belief, and the general rule of variation of forms in here-
ditary transmission makes it improbable. I think, indeed,
tliat historic evidence would support the belief that in
some instances, even within the life of history,^ diseases
liave been greatly modified in hereditary transmission ; ^
that some which were once prevalent and well-marked
can now scarcely be recognised, while others, if they
existed at all in times far off, existed in some form very
unlike wliat we now see. But, even if I had skill for
reading history, I should suspect that no ancient records
w^ould be sufficiently minute to justify our founding on
tliem any useful pathological belief. I think that tlie
best cliance of findinjx trutli concernino- tlie evolution of
diseases is in endeavouring to discern the relations between
the varieties of form in which the same or allied diseases
appear in different members of a family, either in the
same or in successive generations.
* ' History was born on tl)nt night wlion ^Mcxses led the children of Israel
out of the land of (joshen.' — IJunsen'.s 'God in Ilistor}-.'
^ For instance, I should have believed that leprosy, whicli was once
common in England, is now fading-out in the various forms of keloid,
sch'riasis, and other allied skin-diseases, if it were not that Dr. Frtgge, who
lias studied the subject witli an adniirablo care, is against this belief. —
'Guy's Hospital Ileports/ 1808, p. 32."5.
EVOLUTION OF DISEASES. 363
The chance of finding exact truth is, we may admit,
very small; the smaller because, in any group of cases
that we may study, there will, probably, be some in
which disease is become greater, deviating further and
further from the type of health, and some in Avhich
it is becoming less through the constant tendency to re-
covery of health and reversion to the type. If this be so,
we must expect to find in the same family examples of
both the evolution and the involution of disease : the one
a series of forms receding from the type of health, the
other a series of forms returning to the type, and the two,
if not quite alike, yet very hard to distinguish from each
other. Still, since we may be sure tliat there is truth
somewhere, we should seek it with all our might. ^
The fact (as I think) that, in members of cancerous-
famihes, not only recurrent tumours and rodent ulcers>
are much more frequent than in other families, but fatty
tumours and liarmless warts and nodular growths of skin,,
may be explained on a theory of evolution of disease.
Similarly, we may explain the frequency of the whole
group of lithic acid diseases in the families of the gouty.
We may fairly doubt whether any external condition or
any mode of life could produce complete gout in one
having no hereditary disposition to it. But we may fairly
believe that excesses of nitroo'enous food, with beer
or other fermenting drinks, continued through several
1 The wonderful facts discovered by Brown Seqiiard, and briefly related
in his paper '• On the Hereditary Transmission of Efl'octs of certain Injuries
to the Nervous System/ in the ' Lancet/ January 2, 1875. are enough to
encourage enquiries in all directions, even in tliose which seem least likely
to lead to truth. Who would have thoug-lit it possible that the division of
a guinea-pig's sciatic nerve could lead to the production of offspring- toeless,
with outstanding eyes, epileptic.
364 STUDY OF CONSTITUTIONAL DISEASES.
generations, will accumulate the conditions of the litliic
acid diathesis till they culminate in complete gout. And
we may believe that different members of any family in
which this process is going-on, or has been achieved, will
present as many different examples of the lithic acid group
of diseases.
Further, I will hazard a guess, if only for illustration
of the study of evolution of disease which I want to re-
commend ; that the evolution of cancer in many genera-
tions may be studied in the whole group of hereditary
morbid growths. We may begin with cases of monstrosities
by excess, such as those of supernumerary ill-formed lingers,
among which are some that recur once or more after re-
moval. These are hereditary and no hard line of dis-
tinction can be drawn between them and the fatty,
glandular, and cartilaginous over-growths, wliich deviate
from the body's type in shape, yet are not defmed in
outhne, as are tumours, and are not unlimited in ixrowth.
These, again, cannot be separated by more tlian arbitrary
verbal definitions from the tmnonrs composed of similar
structures which are, indeed, separate and circumscribed
growing overgrowths, but ai'c very rarely found imbedded
in structures unlike their own, and very rarely recur after
excision, and very rarely nudtiply themselves by growing
into bloodvessels or lymphatics. The gradual diflerences
among these hereditary growths are not more than are
common among the well known variations of specific
forms in domesticated animals and ])lants.^ And it is no
abrupt step from these; and tlie like tumoni's, the ' inno-
* It seems linrdly necessary to say llial my suggestions respecting the
evolution of diseases have come through a study of Darwin's works.
EVOLUTION OF DISEASES.
3o>
cent tumours ' of clinical surgery, to the recurrent
tumours, whicli are composed of the same structures in
embryonic forms (spindle-cells, round cells, and the rest),
which recur after removal, and not very rarely grow into,
or detach cells into, the blood-vessels or the lymphatics,
and thus, in a measure, infect the blood and are gene-
ralized. From such a disease as this we may imagine that
further variations in many hereditary transmissions would
bring-out cancer, apt to grow in any parts, with struc-
tures even more elemental than the embryo-structures of
the recurrent tumours, always recurring after excision,
always infecting lymph and lymphatics and through
them, or more directly, always infecting the blood.
But if the evolution of cancer may be guessed at in a
series of diseases such as this, then we may expect that,
among the recurrent and other tumours that we see in
families in which cancer also occurs, some are instances
of its involution, instances of forms of morbid growths in
process of gradual reversion to the healthy types of shape
and structure.
I hazard another guess : — that syphilis, of tlie exist-
ence of which there are some vague hints in records soon
after the ' birth of history,' may have begun anywhere
or in many places in multiplied and mingled uncleanli-
nesses, and that its forms may have changed through
changes in the susceptibilities of those descended from in-
fected ancestors, till we can hardly recognise in what
we see the likeness of what was long ago described.
And although I am not nearly ready to believe, as some do,
that all scrofula is derived from syphilis (I could as soon
beheve that all rheumatism is so derived), yet I cannot
366 STUDY OF CONSTITUTIONAL DISEASES.
doubt that some of tlie diseases commonly grouped with
scrofula are forms of syphilis varied by inheritance, and
tliat these diseases are ao-ain variable in either direction
towards greater disease or towards health.
These are mere guesses : but they are good enough
for illustration of a belief in the evolution of heritable
constitutional diseases ; a belief wliicli will not be proved
to be absurd by any proof of the absurdity of my illus-
trations. Whatever may have been the beginning of
each of these diseases, whether in some changes produced
by external conditions, or in some falsely called casual
malformation, it is most probable that the forms in which
they now appear have been attained through a long
series of chansfes. Processes of gradual evolution through
similar forms may be even now going-on, and processes of
involution, or gradual return to health : but I do not
believe that, through any external conditions Avliatever,
and independent of inheritance, any one can become the
subject of cancer, gout, tuberculosis, or any of tlie
diseases allied to tliem. External conditions may liasten
the appearance of such diseases, determine their seat, and
variously modify them in the person affected, but seem to
me utterly inadequate to originate them.
KvioKXcr: of iniieritaxcp].
Wlien any one says ihat no instance of this or tliat
disease lias ever occurred in Iiis family, the statement is
scarcely worth recording, even though it be made with
much more than usual consideration. Very few persons
have a clear knowledge of the healths of their four u^rand-
EVIDENCE OF INHERITANCE. 367
parents, and I never found one who knew anything useful
about the healths of his eight great grandparents ; to
say nothing of the sixteen of the previous generation.
Yet, from any of these, or from other still more remote
ancestors, any disease, or any considerable feature of a
constitution, may be derived. Thus derived a disease may
appear, as true leprosy sometimes does among us, like a
novelty, inexplicable and causeless, or it may be erro-
neously ascribed to some external cause. We may
believe that the probabihties of inheriting a disease
decrease as the distance from a progenitor in whom it
occurred increases ; but we know^ nothing of the rate of
the decrease, and the probability of inheritance does not
fall to zero in. any such number of generations as we are
practically concerned with. There is, therefore, very
little if any value in any negative evidence against a
disease having been inherited.
I wish this were not true, for I am conscious that,
like Brown Sequard's facts just cited, it leaves one too
free to guess at the inheritance of diseases : but it is true,
and we must use cautiously the liberty of guessing.
I may here notice a common error of expression
which would imply that all qualities inherited are also
constitutional. For instance, one hears people say that
their inability to digest this or that, or to bear some
naanner of life, or some kind of air or water, or to exercise
some manner of thinking, is constitutional, ])ccause it is
inherited. It may be so ; but, just as likely, it is only an
inherited likeness of stomach, or bowels, or lungs, or
brain : for family likeness of course involves a likeness of
internal organs just as much as of external ones. A man
368 STUDY OF COXSTITUTIONAL DISEASES.
may have a stomacli like his grandfather's just as he
may have a nose or a mouth hke his grandmother's ; but
neither of these would alone signify a constitutional inhe-
ritance. Xeither would tlie inheritance of an admirably
organised pulmonary tissue, any more than that of a
charming complexion. Such inheritances are, indeed,
important in clinical study : but they must be studied as
personal and local peculiarities, not as constitutional.
MUTATIONS OF LOCAL AXD COXSTITl'TIOXAL DISEASES.
It is often said that local diseases tend to become consti-
tutional and constitutional to become local ; and there is
sufficient seeming truth in this to add to tlie difficulty of
defining the two groups.
But the expressions are seldom exactly true. It is
true that few, if any, local diseases or injuries can exist
long without producing some constitutional disorder, some
morbid condition of the whole economy; and in this way
it is said that the local becomes constitutional. J^ut it
would be more proper to say that the local disease or
\\\]\\v^' j[)roducei^ a secondary constitutional disease, a con-
sequence rather than a contimiance of itself. A local
disease may be said to hcconie constitutional when its
materials pass inlo blood-vessels or lymphatics and are
carried unchanged to any or all parts, and in them mul-
tiply or gi'ow. Thus a cartilaginous growtli, or any of
the softest recuiTent tumours, may generalise itself and
become constitutional ; but these are comparatively rare
events and accidental.
On tlie other liaiid when the chronic rlieuniatic
arthritic disease has appeared, or, as it is said, ' settled^ in
LESSER SIGNS. 369
a liip-joint (for example) it seldom attacks any otlier
joint with severity if at all : and thenceforward it may
seem as if it were a simply local disease. The local
morbid process alone may now vary, and the constitu-
tional disease may seem satisfied or determined and ended
in a single local manifestation ; as if it had become local.
But these cases, again, are comparatively rare and may
be fallacious. The more common course is that a disease
loses little or none of its constitutional character in local
manifestations, or loses it only for a time, as we may
suppose in the cases of gout in which general relief is felt
during or after a local attack. And the most common
course is that, the constitutional disease abiding or in-
creasing in intensity, its local manifestations accumulate :
as in gout, or chronic rheumatism, crippling one joint
after another, and every year attacking some old or new
part ; or as in scrofula, in which one sees wretched
children with eyes, ears, nose, lips, bones, joints and other
parts successively attacked and all continuing unhealthy
till the children die, or till, with increasing age, the in-
tensent period of the constitution may be passed.
THE LESSER SIGNS OF CONSTITUTIOJS^AL DISEASES.
Some constitutions, as I have already said, when they
are well marked, may be discerned by general aspect or
habits, or by singularities of health, or of repair of injuries ;
but, generally, each morbid constitution is to be clearly
discerned only in localised diseases which are charac-
teristic, either in some morbid product or in some method
of morbid process.
B B
370 STUDY OF CONSTITUTIONAL DISEASES.
Each of the chief morbid constitutions has, for its
signal and complete evidence, a certain localised disease,
regarded as decisive; a pathognomon. Gout has the
t^^pical transient acute inflammation of joints, especially
at the great toe : tuberculosis has tlie tubercular pulmo-
nary phthisis : rickets the ill-developed and ilhgrown
bone too readily bending : the lithic acid diathesis, and
the oxalic have their several characteristic urinary de-
posits ; and so on. Similarly, syphilis, whether inherited
or acquired, has its distinctive localised signs ; distinctive
in the same deo;ree and meanino- as are the local evidences
of fevers and the like pervading diseases.
Commonly, patients are not called gouty, tuberculous,
or by any similar name, till they have proved their claim
by suffering some typical local disease ; but in tliis there
is more of convention than propriety ; for they may
deserve their names as truly before and after as during
the full evidence of claim. For, in all these cases, the
local morbid process is a sign, not only of a temporary
localised disease, but of a life-lasting general method of
work in the whole economy, a method which has been
going-on to the time of the local disease and will, pro-
bably, contimie after it.
Consistently with this, each morbid constitution is apt
to give to what may be called common disease such as
may be excited in healthy persons, and to the conse-
quences of injuries, certain features of its own, by which
the common morbid process is inodified in time, or
method or results. Hence we speak of gouty, and of
€y|')hilitic, and of scrofulous ' inflammation ' of joints and
bones and other parts.
LESSER LOCALISED DISEASES. 371
But, further, most of tlie chief morbid constitutions
are indicated by lesser localised diseases which, singly,
may be less characteristic, but, in their combinations,
whether in one person or in many members of a family,
are not less characteristic of the constitution than is the
pathognomon, the signal or typical localised disease. A
man may never have had enlarged or suppurated lymph-
glands discharging curdy pus, and slowly healing with
red-banded and barred scars, yet, if in various periods of
his life he has had pustules by the edge of the cornea,
frequent impetigo with swollen glands, swollen mucous
membrane over the lower turbinated bones, periosteal
swellings of phalanges, chronic thickenings of synovial
membranes, otorrhcea, or any few of these, he may justly
be called very scrofulous, and scrofula may be suspected
in any localised morbid process in him. Or, if these
diseases are known to have occurred singly or together in
many members of a family, we should look-out for scro-
fula as an element of whatever disease may appear in any
member of that family.
Similarly, if a patient has had ' dyspepsia more or less
troublesome, frequent deposits of lithates, slight eczema-
tous eruptions from time to time, anomalous pains in
various muscles, sharp deep-seated pains in the tongue
existing for two or three days and then disappearing alto-
gether for a while, crackling about the cervical spine on
slight movements, more or less, sometimes a mere sus-
picion, of knottiness about the smaller joints of the fingers,'
we may be nearly as sure that lie is gouty as if he had
had the most typical gouty inflammation at the great toe*
For all these lesser diseases, which I quote from an enu-
bb2
372 STUDY OF CONSTITUTIONAL DISEASES.
meration by Mr. Prescott Hewett/ are especially preva-
lent, if not exclusively found, in those who, at some time
of life, display the more signal local manifestations of the
gouty constitution, or in members of the same family
with them.
But the question constantly arises, and it would be of
immense value if we could always answer, — which, if any,
of all these and other lesser diseases may be held singly
sufficient for the diagnosis of a constitution ? For some
of them it is very hard to answer, but for some I think
there seldom can be doubt. Thus, for gout, besides those
already mentioned, the nodules in the ears, formed by
urate of soda in the fibrous cartilage, are, I believe, com-
pletely characteristic. Not less so, I think, are the nodu-
lar enlargements of knuckles frequent in elderly persons
who, though members of gouty families, may have been
free from any more acute form of gout, and may
even not show this till very late in life. Thickening of
the cutis, with subcutaneous bursas over the knuckles,
chiefly between the first and second phalanges of the
fingers are, I think, seen only in the gouty, imless when
they are due to some habitual occupation. Similarly
characteristic, but subject to the same ' unless,' are
thickenings of tlie palmar fascia adhering to the cutis and
producing contraction of the fingers. I cannot remember
to have heard any ])atient complaining of spontaneous
pain ill Iiis tendo Achillis, except such as I knew to be by
inheritance disposed to gout or a lithic acid diathesis.
Pain in the heel of an elderly person has, generally, the
^ ' Trans. Clinical Society/ vol. vi. p. xxxvii. 1873.
LESSER LOCALIZED DISEASES. 373
same meaning ; and so have frequent erections at night
waking fr'om sleep and long persistent, and not connected
with any sexual feeling. ' Burning soles,' and the less
frequent ' burning palms ' generally signify a gouty con-
stitution or one closely allied to it ; and so do the sensa-
tions of hot, tingling, and burning patches of the skin of
the thighs, without external appearance of redness or
eruption. Some persons have, at times, their only indi-
cation of a gouty inheritance in a single patch of dry
eczema (if this contradiction of terms may be allowed).
Edward Jenner had such a patch in which he noted
changes coincident with variations of his general health ;
and I often saw with such an one on his leg a gentleman
whose father, uncle, cousin, and other relatives were typi-
cally gouty, and in whom the spot was affected for the
better or the worse by all those things which the
thoroughly gouty generally find to be good or bad for
them.
I think I might safely enumerate several more small
ailments significant of the gouty constitution ; but these
may suffice. Trivial as they may seem, there is not one
of them but may help the diagnosis of obscure affections
occurring in the persons in whom they are or have been ;
and there is not one of them that can be cured, if at all,
without recognising its constitutional origin.
It seems probable that with careful study we might
discern as many lesser signs of other constitutional
diseases as of gout.
In the tuberculous and scrofulous many minor affec-
tions are seen. In scrofula they are, generally, more
uniform than those in gout, in that tliey all display the
374 STUDY OF CONSTITUTIONAL DISEASES.
cliaracters of slowly progressive and long abiding inflam-
mation, provoked by less causes than would excite
inflammation in healthy persons, and that in the inflam-
matory process many tend to the production of ' cheesy '
matter. When these characters exist, even in trivial in-
stances, scrofula may be discerned, and even without
these there are certain instances of it.
Permanent incisors with their borders barred, cre-
nated, thin, and brittle are, at least, very suspicious, unless
they can be clearly referred to the defective nutrition at-
tending some casual long illness in infancy. The
swollen, puffed, and congested mucous membrane over
the lower turbinated bone is, I think, always charac-
teristic of scrofula in children. Equally so is the
long abiding ozoena of later but still early life, with
frequent or dail}^ discharges of scabs. Allied with this,
and like it a sign of the scrofulous constitution, is the
general swelling, with glandular enlargement of the whole
naso-palatine mucous membrane. The granular pharynx,
Avith its lining membrane more or less thickly scattered
with prominent glands, looking like the first part of the
duodenum with the Bruini's glands, is, I believe, signi-
ficant of tuberculosis. And there is a form of perforating
ulcer of the nasal septum which I believe that I have
never seen except in a member of a tuberculous family. It
makes an oval or circular opening, about half an inch in
diameter, through tlui centre of the cartilaginous part of
the septum, the cartilage being first removed, then the
mucous membrane ; but beyond this extent it very seldom
proceeds, unless in. those who are syphilitic as well as
tuberculous.
I presume that this perforating ulcer is an instance of
LESSER LOCALIZED DISEASES. 375
Lupus exedens, a generally scrofulous or tuberculous
disease wherever it may occur, whether in the face, vulva,
or uterus ; and I suppose that the simple perforating ulcer
of the stomach may be placed in the same group as a
disease of the tuberculous.^
In the fm'ther study of the lesser signs of constitu-
tional diseases, the design should be to arrange groups of
diseases significant, each in its measure and degree, of the
several constitutions. As yet such groups cannot be well
defined ; but the confusion and defects of our diagnosis
would be even greater without such groups as we have
than with them. Perfect groups might be arranged, if
we could gather facts enough, by making each group
consist of those diseases which occur exclusively, or most
frequently, in the lives of some hundreds of those persons,
or families, in whom a single typical constitutional
disease is well marked. And in the selection and study
of these lesser diseases we must not be afraid of looking too
low, or to things that seem trivial. If, for instance, a man
can never drink port wine or beer without being made ill,
this is not a trivial fact. Nothing is trivial which is
natural ; and it may be well to remark that we are very
imperfect judges of what is less and what more important
among the signs of constitutional diseases. We are too
ready to be guided by what we regard as types and good
specimens ; a readiness which has led to manifold errors
in both natural history and pathology.''^
^ I liave not attempted to distinguish tuberculous from scrofulous
diseases. Among surgical cases the distinction seems to me impossible, and
in inheritance even the most marked forms seem interchangeable.
^ On the subject of this section and, indeed, on the whole subject of
Constitutional Diseases, Mr. Gant's 'Principles of Surgery' should be
studied.
376 STUDY OF CONSTITUTIONAL DISEASES.
THE DISCOVERY OP COXSTITUTIOXS BY INJURY AND
DISEASE.
xVmong the least evidences of constitutional disease,
which are yet of high importance in surgery, are some of the
instances in which such disease is discovered or brone^ht-
out by local injury or general disturbance of health, as in
fever or mental distress. It is a mark of a constitutional
disease being highly developed when its local manifesta-
tions appear without any adequate external cause ; when,
as the common expression is, they ' come of themselves,'
or after some trivial disturbance such as l\ealtliy people
bear with impunity ; and when they abide long after the
external or exciting cause has ceased to act.
But there are many persons in whom slight injm'ies or
slight general disturbances of health bring-out no signs
of constitutional disease. These are reputed healthy ;
yet they display the evidences of constitutional disease
when their nutrition is seriously impaired either generally
or locally. Speaking roughly, the intensity or quantity
(I know not whicli best to say) of a constitutional disease or
disposition to disease may be estimated as in an inverse
proi)ortion to the amoinit of disturbance requisite to
pennit or bring-out its local manifestations. In the most
scrofulous cliildren, for exam])le, the lymph-glands enlarge
and threaten su])])uration at degrees of irritation such as
in healthy children would be unobserved : in some, every
scratch ' festers ;' in some, every strained joint inflames.
In the great majority of cases it may be suspected
that when an injur}-, which has been wisely treated, is not
DISCOVERY BY INJURY AND DISEASE. 377
recovered from in due time, i.e.^ in tlie time usual in
healthy persons, it is because of some constitutional
disease, or of too long disuse. Of the latter I have
spoken in another lecture ; of the former you may see
cases every day. A man sprains his ankle and, soon
after, there appears, at the place of injury, an inflam-
mation characteristic of acute gout ; or, it may happen
that the shock of the injury, or the general disturbance
of nutrition following, lets gout appear in some part even
more apt for it than the part recently injured. In
another, after similar injury, the trouble lingers with pain,
and stiffness, and occasional swelling, and with constantly
increasing distrust of surgery, till some one suspects a low
degree of gout and, acting on the suspicion, cures the
trouble. In another, the injured part remains weak and
swollen with puffy integuments, often seeming to get
well, and then, on any exertion, relapsing ; never quite
free from pain yet never very painful ; but slowly be-
coming more swollen and more misshapen till it is evi-
dently the seat of scrofulous disease. In another, after,
it may be, a period of apparent recovery, a painless
swelling appears, and increases, and at length is evidently
cancerous.
Now, all these persons, before they were hurt, may
have been reputed healthy ; and it may be believed of
some, of whom these histories have been told, that their
constitutional tendency might never have appeared if it had
not been discovered by the injury, impairing the nutrition
of a part, so as to permit or make it apt for the locali-
sation of a constitutional disease. The frequency of such
cases suggests caution in all instances of injuries befalling
378 STUDY OF CONSTITUTIONAL DISEASES.
persons of known constitutional dispositions. And among
those whose dispositions are not known certain suspicions
are always wise ; as that when, in a middle-aged or
older man, an injured joint remains long stiff and painful,
without marked heat or much swelling or fever, the
delay in recovery is due to some measure of gout or
chronic rheumatism requiring hot appliances and, not in-
action but, friction and exercise and even violent move-
ment. Or, similarly, in younger persons scrofula should
be suspected : or in those of any age, when the part
remains or becomes the seat of pain altogether beyond a
fair proportion to any other of the consequences of the
injury, some neurosis should be suspected, such as injury
would bring-out from a nervous constitution.
The rule deducible from these and the like cases is
very wide. The process of recovery from injury is, in
healthy persons, as regular in time and method as the
process of development or growth ; when it is deviated
from, it may be because of some local wrong in an other-
wise healthy person, but more often it is because of some
constitutional wrong.
The cases of constitutional disease discovered by fever
might serve to illustrate a large part of tlic convalescence
of fever, a subject of tlie liigliest interest and full of
promise of utility to one who will carefully study it.
The se(|uela5 of scarlet fever are commonly enumerated ;
those of typhoid fever, especially those seen in surgical
practice, are scarcely less numerous but seem less known.
I dou])t whether the reason of the great variety of the
hequelaj has in eitlier case been sufficiently studied. It may
be that some of the diversities are due to different trans-
DISCOVERY BY FEVER, 379
formations of fever-poisons ; and this may seem very
probable if we compare the sequelas of different fevers,
for those of scarlet fever, for example, are different from
those of typhoid. But the differences of the sequelae of
the same fever in different persons are more probably due
to the constitutions, or, it may be, to some personal or
local peculiarities, of the several patients. Certainly it
must not be called accidental or unmeaning if, after
typhoid fever (to name only such cases as I have seen),
some patients have chronic suppuration of lymph-glands,
and some have phlebitis, and some acute periostitis
(some of these being symmetrical and ending with ne-
crosis), and some have chronic suppurative periostitis of
ribs, and some a terrible neuralgia, and some have wasting
of muscles and some a local paralysis.
The common meaning of all these various events
seems to be that, the nutrition of all parts being impaired
by typhoid fever, there is opportunity for the manifesta-
tion of constitutional, or even of local, dispositions to
disease. And this is confirmed by instances in which
different members of a family suffer alike. In one
instance related to me five members of a family have had
more or less extensive paralysis of muscles after typhoid
or typhus fever. And I know a man who had femoral
phlebitis after typhoid, and many years later saphenous
phlebitis connected, I believe, with gout, among whose
relatives three cousins and a nephew have considerable
varicose veins.
The influence of mental trouble in discovering consti-
tutional disease is often very marked. Every one who
has seen much of cancer must have noticed the large
38o STUDY OF CONSTITUTIONAL DISEASES.
number of women who tell of great grief or anxiety just
before the}^ found the disease. Fits of gout follow worry
and overwork : and syphilis long hidden and forgotten
will reappear after fever, or loug distress, or ill-feeding,
or after mental shock. I remember a hospital-patient in
whom a well-marked syphilitic eruption appeared a day or
two after fright at seeing a friend die suddenly ; yet no
syphilitic symptoms had, for some years previously, been
observed in him.
Illustrations such as these may suffice to show the
general rule that injury, fever, mental distress, or whatever
else may impair the nutrition of the whole or any part of
the body, may discover even the lowest degree of consti-
tutional disposition to disease ; and, for another rule, that
there may be no better certificate of health than the
having passed througli a severe fever, or recovered from
some severe injury, without the appearance ofan}'- consti-
tutional disease.
TIME IN CONSTITUTIONAL DISEASES : CLIMAX, DECREASE,
REVIVAL.
A constitution is a life-long thing : but, at least in its
tendency to local manifestations, each constitutional
disease has times of lesser and greater development or
intensity. And generally we may say that for each there
is a time of climax or chief intensity before wliicli it is,
and after whicli it may be, less intense. Thus, speaking
generally, scrofula has its climax in early life, and gout in
middle ac'c, and cancer in advancini]^ vears. But the
deviations from this rule are not rare. Cancer in some
CLIMAX. 381
of its iiitensest forms appears in early life ; scrofula and
tuberculosis may appear first in old age ; gout may
appear in tlie young (though not nearly so often as is
supposed, for its name is often used to cover the hated
name of scrofula).
This occasional untimeliness of climax in constitu-
tional diseases should be well remembered for the sake of
keeping safe from serious errors of diagnosis. The mis-
takings of cancer for scrofula in early life, and of scrofula
for cancer in old age, appear about equally frequent :
and both are more frequent than they should be.
In the cases of those constitutional diseases whose
climax is most frequently attained in the earlier part of
life, there may be so great a decrease of intensity after
the climax is passed, that a patient may seem to have
outlived his tendency to localised disease. An apparent
outliving of a morbid constitution is of practical import-
ance in such cases as those in which a scrofulous joint
is amputated or excised. The probabilities of a favour-
able recovery depend mainly on the degree in which the
scrofulous constitution may have declined from its highest
degree before the operation is done. It is desirable that it
should have declined not only so far that the local disease
should be stationary, but so far that the scrofulous con-
stitution may not be made more intense by the fever and
other disturbances of health which may follow the opera-
tion.
In like manner, one form of the nervous, or neurotic,
constitution, the hysteric (so called), may be in great
measure outlived. As years advance the vivacity of
the central nervous organs becomes less ; impressions are
382 STUDY OF CONSTITUTIONAL DISEASES.
less keenly perceived, less widely and less vividly re-
flected ; the power of attention, even of self-attention, is
diminished ; and after fifty there are comparatively very
few nervons imitations of oroanic diseases. There are
enouo;h to make one cautious in dia<2:nosis : but the chief
caution must be lest organic disease should be overlooked
in what is thought to be hysterical.
But whether a constitution can be in any degree or
measure outlived may depend, not only on its own nature,
but on the time of life at which it attains its highest deve-
lopment. The scrofulous may thus appear to be out-
lived, for it usually tends to decrease before middle age :
the rheumatic, or that form of it which is marked by
acute rheumatism, may similarly be outlived. The gouty
and rheumatic-gouty are not outlived. The cancerous
constitution is not outlived even in appearance, unless in
cases too rare to be reasoned-on ; and tliis not only
because of its usually mortal cachexia, but because in a
constitution it most frequently attains its climax in ad-
vancing years, and tlierefore, in any single case, may be
expected to become more intense as years advance.
We may connect with these facts some of the differ-
ences of the results of amputations. If a scrofulous limb
is removed from a young person there is, often, no further
serious local manifestation of scrofula ; but of the cases in
wliicli I have seen scrofulous linlbs removed at or near
middle age, tlic majoi-ity soon sliowed scrofula in other
parts or died tuberculous. When it was not very rare
for limbs to be amputated for neuralgic joints (he stump
commonly remained neuralgic for many years, but at last
OUTLIVING: REVIVAL. 383
became quiet when the nervous constitution became less
dominant. But of all the amputations of cancerous
limbs that I have known, at whatever time of life, only
one has been followed by freedom from cancer for more
than five years.
But, in connection with this occasional outliving of a
constitutional tendency to localised disease, it must be
remembered that a constitution, which may have been
unmarked or may have declined in one period of life,
may at a later period, and in advanced age, gain
prominence and manifest itself in severe local disease.
Thus syphilis sometimes reappears after many years of
apparent health ; senile tubercular phthisis is well
known ; and in the paper on ' Senile Scrofula ' I have
shown that there is, probably, no scrofulous disease
which may not be found, with all its usual characters, in
even the oldest people, among whom some may have been
evidently scrofulous in earl}^ life, and some may have
shown no previous evidence of scrofula.
Let me add some recent cases of this fact. In a man
of 82, I found abscesses in the scrotum and perineum
with no appearance of urinary or other local cause, under-
mining and opening in many directions. I had long-
known him as one of the finest, sturdiest men of his age ;
active and a leader in business and society. I half
apologised when, seeing no possible origin for his ab-
scesses but senile scrofula, I asked him if he had ever
been suspected of consumption or anything of the kind ;
but his answer made his case clear enough. He had a
family-history of consumption, and himself had had
384 STUDY OF CONSTITUTIONAL DISEASES.
frequent attacks of haemoptysis connected, as he had been
told, with disease in the upper part of his right hnig.
His abscesses remained mihealed till he died at 84. He
illustrated, what I think, is a general rule ; that, the
older the scrofulous patient, tlie less is his chance of
complete recovery from any local manifestation of his
disease ; the less is the good hifluence of all the means
that appear most useful in tlie young scrofulous. So, in
a lady, past 80, who had wx41-marked scrofulous perios-
titis with suppiu:ation on the upper part of her sternum.
It went on long enough to have healed in a young
person, and it showed no untoward changes, but simply
it did not heal, and it seemed to hasten the infirmities of
old aae with which she died. And another, at 91, had
scrofulous suppuration in her lower cervical glands, such
as could not be distinguished from that which is oftener
seen at 9 or 19 ; and this slowly healed ; but it impaired
the good health with which she had previously enjoyed
an active life, and she died with her next attack of
bronchitis.
SUCCESSIONS AND COMBINATIONS OF CONSTITUTIONS.
Thus far I have taken illustrations from ceases in
which the constitution manifests itself in tendencies to
diseases of one ty])c, various in degree but not modified
in quality. But a man may combine in his own con-
stitution, ill any diversity of proportions, parts of the
constitutions of many ancestors, and add to them some
peculiarity of his own ; for no inherited likeness is per-
fect. I cannot here trace out all the confusions
SUCCESSIONS. 385
hence resulting, but I avouIcI recommend the study of it
imder snch titles as the Successions, the Co-existences,
and the Combinations of Constitutions.
SUCCESSIOX OF COXSTITUTIOXAL DISEASES.
If I speak of one constitution being succeeded by
another, this must mean only that at one time of life
one constitution is more fully developed than another,
and makes itself manifest by localised diseases while the
other remains unobserved. It is not rare to find a
patient witli scars of scrofula endured in early life, and
with nodular or otherwise altered joints that were the
seats of gout in later years, and wlio now has cancer.
A gentleman 75 years old had had psoriasis for thirty
years, and during twenty-fi\'e of these he had taken a
grain of calomel (in five grains of Plummer's pill) every
]iight, enjoying all the time excellent general health..
At 75 epithelial cancer appeared and quickly increased
on one of his little fingers. I amputated the finger, and
during his recovery from the operation he had his first
attack of acute gout, a family disease, with wdiich his;
brother, 80 years old, was at the same time suffering.
He died within a year with cancer in his axillary glands.
Many curiosities of succession of this kind might be
traced in the lives of old invalids, and many vain attempts
inight be inade to describe the processes which must in
the same ])ers()n be simultaneous ; the gradual develop-
ment of one ' method of life,' the completion and outbi'eak
of another, the dechne of another. But the subject is.
one of more than curiosity; it has a practical bearing,
c c
386 STUDY OF COXSTITUTIOXAL DISEASES.
especially in diagnosis. The local evidences of a consti-
tutional disease passed-tLrough should not give us an
overweight of prejudice in favour of suspecting the same
disease in all that comes after. It may be present,
indeed, m some lower measure, and, as syphilis and gout
commonly do, may give a tone to any other localised
constitutional disease ; but the local evidence of one con-
stitution succeeding another may be clear enough and
must always l^e watched-for.
I have been im])ressed with the need of this watching
for a succession of different constitutional diseases by
cases in which gout has been suc(*eeded by scrofula.
For instance, a ])atient at middle age had inflammation
of the tarsal \y<\rt of the foot, with excessive heat and
redness and other sicfus from which no one hesitated in
concludimr that he had the c^out, which he was known to
have inherited. But there was no timely subsidino^ of
inflammation, or mere remnant of pain and stifliiess and
some swelling, such as shoidd have ha])pened with gout ;
but after several months a still abidhig soft and l)ulpy
swelling about the tarsus, with dull aching, and with
inutility, wasting of the leg, and other features quite
characteristic of scrofula. The case required for its
recoveiy many months of treatment with splints and care
of the general health, and means tJiat would have been
very ina])])r()priat(i for gout ; and during the recovery
the patient's daughter had scrofulous disease of the hip-
johit.
Such successions of constitutions may be noted in many
other cases. Patients will tell that tjiey Avere very weak
in childhood but grew-nj) strong; others, that they were
CO-EXISTENCES. 387
hysterical or in some way always nervously disordered
till they were at middle age, and became in some other
way disordered. Not rarely one who was tuberculous in
early life becomes at some later time cancerous. In all
alike we may say that one constitution has been suc-
ceeded or become dominated by another.
CO-EXISTENCE OF COXSTITUTIOXAL DISEASES.
Between the Co- existences and the Combinations of
constitutions a fair distinction may be made. Two or
more may co-exist in the same person, and may appear at
the same time, in localised diseases, without mutual in-
fluence, unless in things not essential to either; or, two
or more may combine with such mutual influence that
the result may be called an intermediate, hybrid, or
compound disease. Thus gout and tuberculosis may co-
exist, and neither of them may modify the characters of
the otiier ; so may gout and chancer, and so may any form
of nervous constitution co-exist with gout, or scrofula, or,
I suppose, any other constitution, without modifying any
of its characters except those which are due to nerve-
phenomena.
But, altliough two diseases may thus co-exist without
close combination, yet their mutual influence always needs
consideration in practice. Cancer and gout are often
found together, and each may pursue its separate course,
the cancer in one part the gout in anotlier. In the case
already related of the patient wlio had cancer, gout,
psoriasis, and habitual calomel, I could not see that one
of these had any influence on another. Yet tliere are
c c 2
388 STUDY OF CONSTITUTIONAL DISEASES.
cases in wliicli tlie co-existence of cancer and j?ont need^
care in treatment ; for in patients who have both, the
cancer (as I haA'e observed especially in those in the
breast) is very liable to inflammation and conseqnent
severe pain. I cannot be snre whether this is due to the
gouty constitution or to the plethora with which it is
often associated ; but I think I can be sure of the fact,
and that it is one of the groimds, perhaps the only one,
for the reputation of liquor potassce in the treatment of
cancer. Sir Benjamin Brodie used to give this medicine'
in a large lumiber of cases of cancer and of doubtfid
tumours. I do not doubt that it was often useless ; but
he was too wise a man to oive anvthinf]^ often whic^i
never did good. I ha^-e given the liquor potassos, in
the usual doses of a drachm three times a dav, largely
diluted, and have often seen no effect produced. In one
case, indeed, in combination with small doses of iodide
of potassium, it seemed to cause the absorption of a
great mass of medullnry cancer of an undescended
testicle ; and this not only once, but, after recurrences,
thrice. But, frequently, I cannot doubt that it lias given
relief fi'om the burning, aching, and bmsthig pains which
have been connected, I think, with inflammations of the
cancer — such inflnnunations as I have thouo-ht most fre-
([uent in gouty and pliletlioric patients. To the same or
some similar combination of other maladies Avitli cancer
maybe ascribed, I tliink, some little good that Missisquoi-
water sometimes docs. Its infhience on cancer itself is,
I believe, absolntely noliiing; but it sometimes gives
comfort 'l)y tlie way.'
The co-existence of cancer and general neurosis must
CO-EXISTENCE. 389
be studied. Few diseases are more various in paiufulness
than cancer. It is not very rare to find patients who pass
through the whole course of cancer to their death without
great suffering. I remember one who begged that her
breast, with a great mass of ulcerated cancer in it, might
be removed, only because she could not endure the sight
and smell of it : of pain she said nothing and felt very
little. Others endure agonies ; and we may be unable to
detect anything in the local conditions of the different
cases to explain this great difference in their degrees of
pain. The difference must depend, I think, on the
different characters of their several nervous systems, and
in those who suffer most we may generally believe, for
we often see, that a morbidly neurotic constitution co-
exists with the cancerous. Wherever this occurs, the two
constitutions should for treatment be considered sepa-
rately; and the neurosis should be dealt with as if it
were the patient's only trouble.
It would be difficult to overstate the utility of studymg
the co-existences of different constitutional diseases in the
same person : in each case each of the diseases may need
to be separately treated. The study may go with that of
the so-called antagonism of diseases. Some appear very
rarely to make progress at the same time. Cancer and
syphilis, I think, very rarely do so, even when, as com-
monly happens, cancer has its first seat on a tongue or
lip that bears marks of sy[)hilis. And cancer and tuber-
culosis, though their effects are often fomid in the same
body, do not, I believe, make ])rogress together; when
one is active, the other is slow or stays ; and sometimes
390 STUDY OF COXSTITUTIONAL DISEASES.
they appear in nearly alternate progress, as if in a strife
for which shall kill.
COMBIXATIOX OF COXSTITUTIOXAL DISEASES.
In the combinations of constitntional diseases the cha-
racters of two or more may be so mingled that a localised
disease may combine the distinctive featnres of both or
all. Thns gont and scrofula may be combhied. I think
it was snch a combination that I saw not Ions; since in a
patient, Go years old, who had well-marked scrofulous
disease in the metatarso-phalangial joint of a great toe.
Her father, four brothers, and three sisters died young
with consumption ; and her one living brother was gouty.
It seemed as if inherited scrofida had determined the
general character of her disease, and inherited gout its
locality.
Very important are the combinations of syphilis.
Among all constitutional diseases, whether it be inherited
or acquired, syphilis a])pears to be the most miscible (if
this expression may be allowed), and tlie methods and
degi'ees in which it is modified by the several constitu-
tions of those into wliom it is introduced deserve mucli
more study tlian, so far as I know, they have yet re-
ceived.
A <j[eneral survey of a. lari^e uumberof cases of syphilis
justifies a general descriplion of the disease which may b(i
generally true. But in this large mnnber of cases some
would be found not conforuied to tlu^ g(Micra1 des(Ti])ti()u.
It would be difficult lo find two persons who, being ino-
cidated witli the same sy])hilitic poison, would display
CO MB IN A TIOX. 391
exactly tlie same consequences from beginning to end.
Why would they not ? We must not talk of chance or
accident ; and differences of circumstances would seldom
suffice to explain such differences of result. These differ-
ences seem due sometimes to previous diseases, some-
times to inherited local liability, but more often than to
all other things to^^ether to the differences of the consti-
tutions of those into whom syphilis is introduced. This
is, I think, most plainly seen in tertiary syphilis ; though,
indeed, it is seldom difficult to discern it in the course of
even primary S}q3hilis. In tertiary syphilis I cannot
doubt that, in the great majority of the cases in which the
ulcerative processes predominate, the acquired syphilitic
constitution is combined with a scrofulous or tuberculous
one, while in the majority of those in which diseases of
jomts or bones without ulceration prevail, the syphilis is
combined with an inheritance of rheumatism or gout.
In any given case it may be very hard or impossible
to analyse the complex constitutional state which results
from inheritance, from syphilis, from treatment, fi'om
variety of cuxumstances ; but one broad rule of practice
may be safely laid down — that in every case of syphilis
it is essential to discover, if possible, the inherited consti-
tution of the patient and, in any necessary degree, to
treat that constitution at the same time as the syphilis is
treated. Thus to any one who has marked scrofula, or
tuberculosis, or a tendency to it, mercury is to be given
only with extreme caution. In such ])atients it may often
be better to leave even primary syphilis to its own course
than to give mercury ; and when it is given it should be
in conjunction with cod-liver-oil or iron and good food,
392 STUDY OF CONSTITUTIONAL DISEASES.
and whatever other means may be necessary to avert the
risk of hastening^ the course of the scrofula or tubercu-
losis. The same rules nuist be held m the later stages of
syphilis. The tuberculosis or the scrofula, or whatever
else, must be treated at the same time as the s}^:)hilis, not
only for their own sake but because they hinder the right
action of the remedies specific for s}^)hilis.
This seems to me very marked in many cases of the
combination of gout and tertiary syphihs. The diseases
of joints, the muscular and neuralgic pains, which are
most commonly the results of the combination, are some-
times tractable w^itli iodide of potassium given in any
ordinary way ; but often they require, or at least are
much more quickly cured by, the combination of remedies
for gout and syphilis. In many such cases iodide of
potassium, given in even large doses in the ordinary
manner of a draught, has ap])eared nearl}^ impotent ; and
then, with no other change of conditions, lias been effec-
tive when even small doses were given largely diluted
with some alkaline water, and with regime] i ap})ro})riate
to the lesser forms of gout. It is on this ])rinciple I think
that we may ex])lain a great ]^art, if not the whole, of llic
success of treating sy])hil is at some of the health-resorts
of the Continent. "^Jlie sy])hilitic and the rhemnatic, or
gouty, or other constitution are treated at the same time :
and mercury or iodide of ])otassium is given while the
patient sul)mits to the 'waters ' and the ])rudent regimen.
I might nuillij)ly such suggestions for ])ractice, but
they would all come williiu the sanu^ j'ule oi" tlu; ueces-
«ity of discerning the two oy more constitutions which
may not merely co-exist hut be combined in the sanie
COM BIN A TION. 393
person, and of regarding both or all in the treatment of
every localised disease, even thongh the characters of
this disease may suggest tliat it is an expression of only
one of the combined constitutions.
This must be a rule of practice, even though the
analysis of constitutions which it demands may be some-
times impossible : impossible, because constitutions may
be combined in the most various numbers and propor-
tions, and sometimes with such closeness that one cannot
assign to each its part in the whole result. Tliere may
be complete hvbriditv, in which one can onlv say that
each part of the result is a little more or a little less like
one or tlie other of the original constitutions. Such
hybrid diseases seem to be those of the confused group of
what are called rheumatic 2;out. In tlie combinations of
gout and rheumatism there appears an intricacy past
clearing ; and unhappily the difficulty extends beyond
diagnosis into treatment. Whatever forms we may try
to define with such names as rheumatic o'out, chronic
rheumatic arthritis, rheumatismus deformans, and tlie
like, cases are easily found completely filling the intervals
between the groups : and as to treatment it seems only
too true that in the same degrees as the cases deviate from
the typical characters of gout and rheumatism so do they
become less amenable to the treatment useful for either
when apart. Curiously, too, the hybrid disease is compa-
ratively insusceptible of the ill consequences of the errors
of diet which aggravate gout and, in a less degree, rheu-
matism. Many of those who have the most marked chronic
rheumatic arthritis, which seems to be a form of combined
394 [STUDY OF COXSTITUTIOXAL DISEASES.
gout and rheumatism, can eat and drink ^vliat they please,
^vith at least as much impunity as most healthy people
can.
LESSER COXSTITUTIOXAL COXDITIOXS.
What I haye said may suggest the need of a much more
constant habit of analysinc^ constitutions than most of us
are in practice accustomed to. We are commonly con-
tent to speak and think of one man as gouty, of another
as scrofulous, another as neryous, and so on ; just as we
are apt to say that one man is good, another bad ; or
that one is cmming, another silly, and so one. But in
neither moral character nor health-character is it common
to find singleness or simplicity. In all characters are
many constituent elements ; one may be yery dominant,
but the rest are not often so triyial that tliey maj' be
safely neo-lected. Certainly it is necessary to o'ood
practice in eitlier surgery or medicine tliat no element of
a patient's constitution should be quite oyerlookcd. Many
of those which we commonly speak of as if they were
sin^de and self-com])lete constitutions may be mingled in
the same person, and yet more \arieties may be deriyed
from tlie combinations with them of some lesser constitu-
tional conditions.
Anionir these is that condition of which I haye often
spoken as 'cold-blooded.' There is no condition which
]naynot be modified by it, and tlie ])eculiarities snggesting
the name should always be obserwd : the liabitual cold-
ness of the feet, the coarse dusky-pink jxipillary condition
of the skin of the legs and tlu* back of the arms, the too
venous aj)i)earance of parts that should be ruddy, the
LESSER CONSTITUTIONAL CONDITIONS. 395
general inactivity and torpor of all the functions, the fre-
(jnently scanty painful menstrnation. For with these
things there commonly coincide a low power of resisting
the ordinary causes of disease, and a slowness of recovery
from disease and injnry ; and, with whatever other con-
stitutional defect or disease the coldness may be combined,
its need of good food and warmth, of long sleep and,
generally, of tonics must be borne in mind.
And there are constitutions even less defined and less
mgnalised than these which yet should be observed. Thus
we speak of the w^eak and the strong in constitution, and
the terms are not mmieaning. Generally, men are called
strong or weak according to their capacities for work or
pleasure, for mental or muscular efforts ; but these capa-
cities have no constant or necessary relation to strength
or weakness of health, though they are often found to-
gether. The highest strength of constitutional health is
shown in that very rare state in which a man passes
through a long life without disease, and dies of old age,
all his fimctions becoming gradually less active and all at
the same time ceasing. This state may be wdiere there
are few, if any, of the popular evidences of health. A
man of 96 told me that he had never deemed himself a
liealthy man : and anotlier nearly as old, who had ne\'er
suffered anything worse than slight indigestion, said tliat
lie had never enjoyed health. Neither of these had been
vigorous in mind or body, but in both there had been
the main characteristics of ' strong ' health, namely, such
tenacity of com])osition in every part, and such balance
of them all, as cannot be distiu'bed by the ordinary forces
396 STUDY OF COXSTITUTIONAL DISEASES.
' of disease, or being disturbed can be quickl}^ and per-
fectly recovered.
The o})])osite of this is in the ' weak ' constitution ; the
condition \-ery easily moved to disease, very slowly and
im])erfectly recovering, yet in disease showing no specific
character, no constant or w^ ell-defined morbid method of
initrition or excretion. They wdio are thus w^eak cannot
bear Avith impunity any of the ordinary causes of disease,
as fatigue or great heat or cold : ' every little thing makes
them ill ; ' their illnesses ' come of themselves ; ' from
excitino' causes too slight to be observed.
But a simply wx^ak constitution is as rare as a simply
or completely strong one. The instability which is weak-
ness is generally associated with some definite c^iaracter
of disease ; witli the scrofulous or gouty or some other
morbid constitution. Still, mere Aveakness must be
reckoned among the im])ortant elements of personal
character in respect of health and disease, as smely as it
is anionu" those of mental character, or nuiscular i)ower.
And, I re[)eat, nuiscular or mental })ower is not to be
taken as a. mcvasnre of health : in the view of ])athology a
gouty ])erson is weak in the same sense as a scrofulous or
a sy])hiritic one.
Tliere are notable diflerences of constitutions in
res])ect of the times in which the coin\se of life, from
birth to death in senile degeneration, is run. Living to
old ao'e ' L^oes in familic^s,' and so does dyinii; before old
aire. ^J'he time in wliich llie cJian<>'es eiidinc^ in the senile
degenerations are aeliieved is in the one gronp of j)ersons
mucli longer than in llie oilier. Often, indeed, the
earlier or Inler dying is because of inherited diseases, of
LESSER CONSTITUTIONAL CONDITIONS. 397
Avhicli some are earlier some later developed. But some-
times it is plainly because the degeneracies of old age are
quickly reached; not only, it may be, in tlie hair or
teeth, but in much more important structures or in all
parts. It is, probably, due to this that in some families
many members die at or near the same age, soon after
middle life ; and these do not all die of the same disease,
l)ut it may be of various casual diseases or injuries, as if
they had all lost before the usual time tlie })Owers of
repair.
Another unpunctuality of life is obser\'al)le in the
cases of delayed puberty, and of delayed matmity of
manhood or of womanhood. This may be seen in some
who, in early life, have had some se\'ere illness which
.seems to have delayed their development ; but in others^
and not rarelv in several members of the same fiimilv,
tlie delay seems to be onlybecause the same changes are
more slowly wrought in these than in the average of the
same race or class of persons. The speed of life is not
the same in all.
J
NOTES
Note J., jpage 5.
In the following note I have endeavoured, by using experience
gained at the Children's Hospital, to discuss the various risks of
operations in childhood more at length than the space that
could be allotted to the subject in the text would permit.
A few hours of acute pain will suffice in young children to
induce a dangerous degree of collapse. This was shown in a
case of strangulated hernia of only about sixteen hours' dura-
tion, in a boy four months old. Strangulation set-in at about
five in the afternoon, and the child was in great pain, and
screaming almost incessantly through the night. In the
morning he was very pale, with his features pinched, his eyes
dull and sunken, pulse small, rapid, and hardly to be felt at the
wrist, respiration hurried and shallow, skin cold and clammy,
and there had been several slight convulsions. After his hernia
had been reduced by operation he rallied at once, and all
symptoms of collapse soon disappeared. Another child, two
years old, the particulars of whose case were sent from the
country, died apparently of the pain and terror caused by the
repeated dressings of a burn on the trunk and lower limbs.
During the intervals between tlie dressings lie appeared to be
doing well, and his wound, at the end of a fortnight, was covered
with healthy granulations : but each of the dressings left liim in
a prostrate condition, and after one of them he died. On two or
three occasions young cldldren who had been sent to their homes
400 NOTES.
after operations for Lare-lip, or the ligature of large iioevi, and
who Imve suffered severe pain for some hours subsequently, have
been found next morning in considerable peril from shock.
Happily the means in use for preventing or relieving pain in
adults may, witli proper caution, be safely employed for
children. All know liow well even weakly and puny infants a few
days old take cldoroform. It should be given not only for
painful operations, but also for painful dressings. From what
was reported at the time it seemed probable that the burn-case
just referred to would liave ended in recovery if chloroform had
been used wlien the wound was dressed. Opium must always
be given with great care as to its quantity, and, as Dr. West *
points out, in preparations of uniform potency ; but thus
employed, it is perliaps the most valuable medicine that
cliildren ever take. At the Hospital for Sick Children opium,
cliiefly in the form of the tincture, is constantly prescribed after
operations and otherwise, j ust as it might be for adults.^
It is often said that cliildren bear the loss of blood badly.
It would lead onl}^ to evil if doubt were thrown on this belief in
a form that could, by any possibility, produce a disregard of
lunemorrhage in operations on children : yet it may be questioned
whether the opinion is well founded. I have on two occasions
known children make a good recovery from operations which
left them l)lanched and nearly pulseless. One of these patients
was an infant ele\en days old from wliose parotid and pterygo-
maxillary regions a Ijirge congenital cystic tumour was removed,
tlu'ough an incision reaching from tlie corner of the moutli to
the zygoma. In the other, a boy aged three, a cyst in the neck
had been punctured, and was soon afterwards found so distended
witli blood tliat it was necessary to lay it freely open. When
this was done by .Mr. Tliomas Smith sucli profuse haemorrhage
followed that in I wo or three minutes the cliild was completely
blanched, and very nearly pulseless. In some cases of haemo-
philia children wlio have bled very largely rally with surprising
rapidity as soon as their bleeding can be stopped. In a case of
repeated secondary lur.'morrhag(» after litliotoniy a boy aged
• ' Diseases of Infancy and ('Iiildliood,' Ifli cl. p. 20.
NOTES. 401
three, lay for a fortnight blanched ta an extreme degree, yet he
quickly recovered when his bleeding ceased. In a boy, aged
six, in whom an abscess connected with hip-disease was
opened, bleeding from the wound was overlooked till he became
pale and faint, but in a few days all traces of the occurrence
had disappeared. I am not aware of any case of death from
haemorrhage after an operation at the Children's Hospital.
Convulsions might be supposed to follow large haemorrhages
in children, but later experience confirms the observation of
Sir William Fergusson, that they are extremely rare from this
cause.
Convulsions having been referred to, this may be the
place in which to mention a danger attending operations on
children, though I have known it realised in only two in-
stances. A child about three months old, who was operated
on for hare-lip, after passing eighteen hours without any
symptom of danger, became suddenly convulsed, and died
in a few seconds. I afterwards learnt that he had previously
been subject to convulsions. I have heard of another almost
precisely similar accident. Tliere was doubtless a special
element of danger in these cases, for the breathing space to
which the children were accustomed had been suddenly very
much curtailed by the operation, so that asphyxia was readily
induced ; yet the result suggests that in all cases of operations
on children it is prudent to ascertain whether there is a history
of previous convulsions.
The various exanthemata should not be lost sio'ht of in
their relations to the surgery of childhood. Allusion has been
already made (p. 349) to the effect which operations frequently
have in determining the appearance of scarlet fever. No
similar relation has been observed between operations and
measles, or indeed any other zymotic disease besides scarlet
fever. But care must be taken that operations are not per-
formed upon children during the incubation-period of these
disorders, or during even slight feverish attacks ; and it is wise,
if there be any doubt as to the patient's state, especially if his
temperature be higher than normal, to wait for the certainty
D D
402 AZOTES.
wliicli a few days' delay will bring. Bronchitis, cough, and
even a severe catarrli, have all led to the failure of plastic
operations in children. And there is need for equal care that
operations are not undertaken in those who have recently passed
through any exanthem, or other serious illness. A dermoid cyst
was removed from the brow of a girl, live years old, who ap-
peared in good general health. Such extensive sloughing
followed, that when the wound had scarred the eyelid could
not be closed. It was then mentioned that the child had re-
covered from a severe attack of measles less than a month before.
At p. 5 Sir James Paget has pointed out that children are
singularly little liable to pysemia after wounds ; a strange
contrast, he adds, to their liability to it in connection with
•acute necrosis. In the few instances which are exceptions to
this rule the affection usually proves to be of a milder and less
fatal type than that which prevails among adults. Children not
seldom recover from an attack of pyaemia which is very acute
at its commencement, and which would generally be quickly
fatal in older people. This comparatively favourable issue is
due no doubt to the perfection with whicli the unimpaired
organs of cliildren perform all the processes of elimination and
excretion. In children, too, medicines, especially the hypo-
sulphites, and the various preparations of cinchona, have
appeared more efficacious than they are in adults.
.Rigors arc rarely seen in children, in whom their place is
taken by convulsions. Dr. West,' referring to tliis subject,
remarks 'Tlie disturbance of the spinal system which ushers
in fevers in the adult shows itself by shivering, while in tlie
child the sjime disturbance often manifests itself by convulsivons.'
This observation should be borne in mind, especially in cases
in which pyaemia is likely to be developed. Tlie occurrence
of a convulsion under such circumstances may afford valuable
evidence for diagnosis, just as shivering may in the adult ;
but unless care be taken this symptom may easily lead to
■error.
Diseases of the liver and kidneys must })e looked for, and
> ' DiscasoH of Childliood; llli oil., p. 3i.
NOTES. 403
if detected be carefully considered as to their bearings on
operations in children ; but the rules used for adults may be
somewhat modified for children. The affection of these organs is
generally either fatty or amyloid degeneration, depending on
prolonged suppuration (p. 29). In the advanced stage of either
form operations are highly dangerous. But, on the other hand,
these conditions are not incurable, and instances might be given
in which enlargement of the liver and albuminuria have com-
pletely, though very slowly, disappeared when suppuration
ceased, and operations performed while these affections were in
their early stage have not been adversely influenced by them.
I believe an operation is not improper, but under favourable
local conditions rather called-for while these diseases are
incipient, for if it can limit the amount of suppuration it
inay be the means of arresting their further advance.
At p. 35 attention is drawn to the possibility that during
the feverish condition which may follow an operation, latent
tuberculous disease may become fatally active ; and an instance
is given of a man in whom acute meningitis set in while he
was feverish after the opening of a large axillary abscess.
This is a source of danger that must not be forgotten in chil-
dren, in whom tuberculous diseases are comparatively common.
Some years ago Mr. Thomas Smith excised the hip-joint of a boy
about six years old. Next morning the patient became comatose
and convulsed, and within a week he died. At the post-mortem
examination several large masses of yellow tubercle were found
in the substance of the brain, and the cerebral meninges were
in a condition of recent inflammation. In another case a girl
was admitted with hip-disease, and was soon afterwards placed
under chloroform while her limb was brought into good position.
She recovered naturally from the chloroform, but next day
became drowsy, and soon showed conclusive signs of tubercular
meningitis, of which she died within a fortnight. Her history was
not clear, but there had been headache and fever before lier
admission. It may be, therefore, that meningitis had already
commenced. Still, even so, the case may be useful as showing
D D 2
404 NOTES.
how much care is necessary to avoid the appearance of sometimes
doino- mischief.
The period of the first dentition is unfavourable for opera-
tions, and should if possible be avoided. Children are not
only irritable and fretful during this process, but are also often
disturbed both in their sleep and their digestion ; and are not
rarclv attacked with exhausting: diarrhoea or with convulsions.
The dyscrasia of syphilis unfits infants for plastic operations.
Children are sometimes found to be suffering from serious
constitutional disturbance and exhaustion consequent on severe
local disease, such for instance as stone in the bladder and
the question arises whether they should be operated-on at
once, or should first be prepared for operation by rest, good food
sedatives, and other appropriate means. Two or three years
ago a boy with stone, admitted under the care of Mr. ^Yillett into
St. Bartholomew's Hospital, was already so much reduced by pro-
longed suffering that it seemed doubtful whether lithotomy might
not fatally tax his remaining strength. ]\Ir. Willett, however,
with the concurrence of all his colleagues who saw the case in
consultation, determined to operate immediately. The boy
rallied at once, and made an uninterrupted recovery. In another
case lithotomy was performed on a boy aged two, who was reduced
to an almost dying state by pain and frequent diarrhoea. He
also recovered without drawback, and his diarrhoea ceased a few
hours after the stone was removed. These cases fairly represent
general experience on this point, by indicating that immediate
interference is usually safer than delay.
Note IL, page 15.
!Mr. Savory, in his lectures on the examination of patients be-
fore operating on them ('Brit. Med. Jour.' 1873, vol. i., pp. 55,
107), has some important remarks on the preparation of patients
for operations, and lie refers especially to such as are intem-
perate. In these, if an operation is imavoidable, he considers
it very important, when circumstances permit, to postpone its
perfornianco for a tiirio, in order, by regulating the habits and
NOTES. 405
4iet of the patient, and promoting the elimination of refuse
material from the system, to bring about a more promising-
state of health, and he insists on the considerable improvement
which may be secured, in some cases, by even a few days' delay.
He discusses the propriety of suddenly altering long-continued
habits of intemperance in the immediate prospect of an opera-
tion, and concludes, that although this course may sometimes
involve large risks, these are certainly less than those that beset
Si patient in whom all preparation has been omitted.
Note III., page 17.
Many surgeons who have practised in India confirm this state-
ment without a moment's hesitation. And yet a somewhat
different impression is derived both from the reports and
statistical tables that have been published of the results ob-
tained in various native hospitals and dispensaries of India, and
from the opinions of Dr. Fayrer and, as regards other coloured
races, of Professor Peaslee, of New York ; and both these are
names of high authority on the subject.
Dr. Fayrer has given the following statistics. ('Indian
Annals of Medical Science,' vol. x., 1865-66). Of 32 amputa-
tions performed at the Medical College Hospital in Calcutta,
namely, 1 at the hip, 3 through the thigh, 10 through the leg,
4 (by Syme's operation) at the ankle, 5 at the shoulder, 5
through the arm, and 4 through the forearm, 18 were fatal. In
9 death resulted from pygemia following osteo-myelitis ; in 3
from pyaemia not connected with bone disease ; and in 6 from
tetanus gangrene or exhaustion. In a total of 115 amputations
performed in the latter half of 1863 in 180 hospitals and
dispensaries in the Bengal Presidency, 26, or 1 in 4*4, were
fatal. In 68 cases of lithotomy in tlie same Presidency 8 were
fatal, or 1 in 8*5 ; and in the North- West Provinces and the
Punjab, in 555 cases 57, or 1 in 9*7, were fatal. A native
surgeon, Eabo Ram Narain, has. Dr. Fayrer states, performed
lithotomy more than 200 times in the stations of Cawnpore and
4o6 NOTES,
Budaon, witli the loss of only 7 cases ; but this success appears
to be altogether exceptional.
In strangulated hernia the intestine, if not released, speedily
beconaes gangrenous ; and even after early operations gangrene
frequently ensues in the portion of intestine that has been
injured. Although in the country districts it is often seen
that severe wounds involving the large joints or the viscera are
repaired, yet these patients are found to evince a low standard
of vitality, and in many instances are attacked with pjTtEmia
or gangrenous inflammations. Dr. Fayrer believes the natives
of India recover, under favourable hygienic conditions, perhaps
as well as Europeans ; but he thinks this is all that can be said
of them.
Dr. Garden (loc. cit, vol. xii.) finds that of 824 cases of
lithotomy performed in the course of eighteen years in a
dispensary at Saharunpore, 108, or 1 in 7*63, were fatal. 'A
very high mortality if the native of India possesses, as he
appears to, a peculiar facility of recovering from operations and
incised wounds generally.' The death rate after lithotomy in
England, according to Mr. Poland, in Holmes's ' Syst. of Surg.'
(vol. iv.), is 1 in 7. I am indebted to Professor Peaslee for a
communication in whicli he says, ' Blacks have, according to my
own observation, far less tolerance of severe surgical operations
tlian whites.' It may be interesting to add from Miss Young's
life of Bishop Paterson, that tetanus is very common after
wounds in the natives of the Polynesian Islands. Several
natives were struck with arrows in the expedition that cost
Paterson his life, and almost all died in a few days of tetanus.
And the same complication, I am told, very common^ follows
even trivial wounds in tlie natives of the district occupied by the
Zambesi mission on the East Coast of Africa.
Note IV,, page 26,
Children so rarely suffer witli strangulated hernia that it is
difficult to speak positively upon any point respecting the
affection in them. But present experience seems to show that
NOTES. 407
they form an exception to this rule ; for in a considerable
number of the cases that are recorded the bowels have acted
— in not a few copiously — without ill effect, from three to six
or eight hours after the operation, and have subsequently
remained regular. (Article by Editor 'St. Bartholomew's
Hospital Eeports,' vol. x., p. 210, et seq,)
Note F., page 45.
Many of the insane are persons who not only enjoy sound
bodily health, but also lead very regular lives, secure in the
restraint under which they are placed from intemperance and
other faults in diet, and from overwork, exposure, and various
influences that make other patients unfit for surgical operations
or the repair of injuries. And many of them derive further
advantage from their indifference to their condition, and freedom
from all anxiety as to the result of their illnesses. This power
of tolerating injury was well shown by the case of a patient
who attempted suicide at Bethlem Hospital, in Sir William
Lawrence's time, by thrusting his head into the fire, and keepings
it there till he had so injured his skull cap that the whole vault
was afterwards separated by necrosis. Yet he suffered very little
in his general health, and lived fourteen years subsequently*
The skull, with the portion that was exfoliated, is in the museum
of St. Bartholomew's Hospital (Ser. I., 100). Mr. Ferguson,
of Cheltenham, has lately published an instance in which he am-
putated the leg of a man who had placed himself, in an attack
of acute mania, before a train on the line. This patient was-
very violent for many days after the operation, and frequently
pulled off his dressings and bruised his stump, yet he made
a good and tolerably rapid recovery, and left the hospital in
about two months.
Mr. Curling records several examples of self-mutilation,
in all of which the wounds liealed favourably ; and lie remarks
that these cases ' generally do well, and the state of mind under
which the injury is inflicted does not seem to operate pre-
judicially to the patient's recovery.' — 'Dis. of Testis,' 3rd ed.,p.84.
4o8 NOTES,
The case, however, is different in some instances of melan-
cholia associated with a general break-down of health from
prolonged mental trouble or overwork, coupled with habits of
intemperance. Thus in attempted suicide, wounds of the
throat remain for long periods pale glassy oedematous and
without progress in healing, while the patients continue quiet
and sullen, and gradually fail in general liealth. Not rarely
they die of exhaustion with their wounds still miclosed.
Note VL, page 84.
Demarquay relates two cases in which this accident happened,
and mentions a third (' Bulletin Gren. de Therapeutique,'
1861, p. 21, et seq.). In one, a muscular and vigorous man,
aged 35, in a struggle with his horse came to the ground
with all his weight thrown upon one foot. lie was unable to
walk, and felt severe pain at the lower part of the leg and in the
foot. No fracture or bone-dislocation could be detected, but
there was considerable ecchymosis in the course of the peronei ;
and on the outer surface of the malleolus a tense cord could be
felt rolling under the finger ; and this was easily returned, when
the foot was extended, into the normal position of the peroneal
tendons. A long compress and a bandage sufficed to keep the ten-
dons in place, and in three weeks the patient could walk on the
limb.
In the second case a young woman jumped out of a window,
and immediately afterwards was unable to walk, and complained
of severe pain in tlie foot. Tliere was considerable ecchymosis
in the lower third of tlie leg, extending from the posterior aspect
of the fibula forwards to the dorsum of tlie foot, and in the space
Ijetween the fibula and tendo Achillis. The peroneal tendons
lay in their natural position, but it was evident they were not
contained in their sheath ; and Demarquay believed they had
been displaced in the fall, but had afterwards slipped back
again into place. Mr. Curling (' ]3rit. Med. Jour.,' Jan. 2,
1809) has r(!Corded a well marked case of displacement of the
peroneus longus. The 'Bulletin de I'Acad. de Medecine,' Jan. (5,
■NOTES. 409
1874, contains a very interesting paper communicated by
M. Broca for M. Charles Martins, in which the latter describes
a dislocation of the tendon of the tibialis posticus forward
on the internal surface of the malleolus, wliich occurred in his
own person. He received this injury by being tlirown violently
down during the landing of a balloon in which he had made
a voyage. The tendon was easily replaced, but he could walk
only with much pain and difficulty, and ecchymosis, extending
as high as the knee, and considerable swelling, followed. He re-
covered with rest and the careful use of compresses, &c., in three
months. M. Martins has given his paper additional value by
making in it a collection of all the examples he could find of
•displacement of nauscles. His list includes, besides the tibialis
posticus, the long tendon of the biceps brachialis, the
triceps brachialis, rectus femoris, sartorius, plantaris, and the
peronei.
Note VIL, page 86.
In this specimen, as in that of Mr. Soden's, for the two are
singularly alike, the long tendon of the biceps has slipped from
its groove about half an inch inwards, and is there confined by
a strong band of fibrous tissue, which passes over it and straps
it down. Mr. Soden's specimen is in the museum of King's
College Hospital (No. 1341).
Note VIII., page 86.
The following is a condensed report of a case given by
Hamilton. {' Fract. and Dislocation,' 3rd ed., Philadelphia,
1866, p. 581.) Mrs. B., aged oQ, was thrown from a carriage,
and dislocated her right shoulder. The dislocation was soon
' reduced,' but the joint remained painful, tender, and disabled
and the patient could raise the arm only a very short distance
from the side. Passive movements, however, were painless
and free in all directions. Seven years afterwards the joint
still remained partially crippled, and on examination at this
time, the head of the humerus was found resting upon the out-
4IO NOTES.
side of the coracoid process, and the slioulder was unnaturally
prominent in front, and flattened behind. A few months later,
in a sudden and thoughtless effort to raise the arm above the
head, the muscles unexpectedly obeyed the will, and from that
time the patient had perfect use of the limb, although the de-
formity still remained. She believed she heard a snap when
the arm went up, but it was followed by no pain, soreness, or
swelling. Hamilton thinks there can be no doubt that the de-
formity and disability here described were due, in great measure,
to a displacement of the long tendon of the biceps.
Note IX., page 86.
Mr. Hey, in his original paper on ' Internal Derangement of
the Knee-joint,' says, ' The leg is readily bent or extended by
the hands of the surgeon, and without pain to the patient ; at
most, the uneasiness caused by this flexion and extension is
trifling. But the patient himself cannot freely bend, nor per-
fectly extend the limb in walking; he is compelled to walk
with an invariable and small degree of flexion. Though the
patient is obliged to keep the leg thus stiff in walking, yet in
sitting down the affected joint will move like the other.'
— (' Practical Observations in Surgery,' 1810.)
Note X., page 87.
This cast, No. 29 in the series of models and casts of dis-
eased and injured structures, is thus described in the museum
catalogue, vol. ii., p. 278, No. 29. 'Cast of a knee in wliich it
was presumed that the internal semilunar cartilage liad been dis-
placed by external violence. Over the situation of tlie cartilage
there was a deep crescentic depression of the integuments (this is
well shown in the cast). Tlie patient was knocked down, and
fell with his left leg bent under liim, and from that instant was
unable to bear on the liml). In examining the limb while the
knee was bent to its utmost, a sudden crack was heard, the
depression of tlie integuments on the inner side of the kneo
disappeared, and the mobility of the joint was restored.'
NOTES. 40
Note XI., page 117.
Mr. Hutchinson (' Lond.Hosp. Eep.,' vol. ii., p. 109) expresses
liis belief that peritonitis very rarely occurs before the operation
has been performed, unless it is provoked by perforation and
faecal extravasation. What are taken to be the signs of peri-
tonitis— sickness, constipation, an anxious expression, a some-
what dry tongue — are really due only to intestinal obstruction ;
while attentive examination will show that, althongh there is a
painful sense of dragging if pressure is made near the neck of
the sac, there is none of that general intolerance of pressure
which marks a case of peritonitis. He points out that when,
as it occasionally happens, patients die of strangulated hernia
without operation, not the slightest sign of peritonitis is found
after death ; and he cites an instance, fatal on the tenth day,
from unrelieved strangulation, in which this was the case. In his
article on Intussusception (' Med. Chir. Trans.,' vol. Ixvii.) his
language is even more positive : — ' In intussusception, as in
strangulated hernia, and other forms of intestinal obstruction,
it may, I think, be taken as an established fact, that unless
actual perforation has occurred, there will be no peritonitis.'
In explanation of the every-day observation that peritonitis is
found in cases of death ensuing very speedily after operations
for hernia, he remarks ' that it is almost impossible to exagger-
ate our conception of the wildfire rapidity with which
inflammation of a serous membrane may commence, and may
extend when once an adequate cause has been supplied.' The
chief causes of peritonitis after operations for hernia lie thinks
are the return of intestine in a state of advanced inflammation,
with flakes of lymph adhering to it, and with spots on its
surface which are approaching gangrene ; and secondly, tlie
injury inflicted by fingers, directors, &c., introduced into the
sac. In all this Mr. Hutchinson finds an obvious occasion to
insist on the necessity for early interference in cases of strangu-
lation ; on the caution required in determining whether a piece
of inflamed intestine should be returned or left in the sac, and
412 NOTES,
on the gentleness and care which must be observed in every-
thing connected with the operation.
Note XIL,pa(/e 124.
Since the lectures on Hernia were given, Dr. Dieulafoy has
published his ' Traite de V Aspiration des Liquides Morbides,'
which contains a chapter of great surgical interest and impor-
tance on the employment of aspiration in the reduction of
strangulated hernia. The operation consists of jiuncturing
the hernia at one or more points with a fine tubular needle
connected with an air-cxliauster, and removing any gas or
fluid that may be present either in the sac or in the
cavity of the intestine. Dr. Dieulafoy refers to numerous
cases in which aspiration has been thus used either by him-
self or by other well-known continental surgeons. In some
of these strangulation had lasted as long as four or five days^
and the taxis had failed to accomplish reduction ; yet after
aspiration the liernia was easily returned. Against thes(^
successes he has to record some few instances in which aspi-
ration failed to procure reduction, but none in which any
mischief resulted. And he concludes that ' la ponction aspira-
trice d'une anse intestinale herniee, pratiquee au moyen de
I'aiguille n" 1, ou n*" 2, est d'une complete innocuite.' The
cases most appropriate for aspiration arc those in wliich the
hernia is formed of intestine witliout omentum, strangulation
is recent, and there are no adliesions. J^ut he thinks it should
be tried in all cases of strangidation, with the single exception
of tliose in whicli there is reason to fear the intestine is
already gangrenous or ulcerated. And he woidd use it before
resorting to tlie taxis. Several surgeons in Eiighuid have.
practised this method, and Jiave olitained many satisfactory
results. But the anticipations of Dr. ])ieulafoy liave not
been fully realised. Asi)iration lias failed in a considerable^
number of cases, and it is assuredly not so free from danger as
J)r. Dieulafoy believed when his lecture was publishod.
There are many conditions which render it impossible or
NOTES. 415,
not right to return a hernia without opening its sac, and in
which aspiration would prove useless or mischievous. At
present the method must be held to be on its trial. It will
imdoubtedly prove valuable when strangulation is recent,
and reduction is prevented by a collection of gas or fluid either
in the sac or the canal of the intestine ; but it must be used
with great care, and only after a very close consideration of all
the features of the case.
Note XIII., 'page 127.
At St. Greorge's Hospital it is the almost invariable custom
to open the sac in every case of operation for strangidated
hernia. Thus in a paper in the ' Medical Times and Gazette,''
vol. i., 1861, it is stated by Mr. Cooper and Mr. Holmes that in
121 cases there were only 4 in which the sac was not opened.^
And Mr. Haward, writing in the ' St. George's Hospital Eeports,'
vol. i., 1866, increases these numbers to 181 and 6 respectively.
In the series of 121 cases the mortality was 30-5 per cent.; and
the authors compare this death-rate with that in 100 cases at
the London Hospital, in more than half of which the sac was
not opened, and in which the mortality was 33 per cent. The
conclusion drawn by Mr. Cooper and Mr. Holmes from these
figures, and from an examination of the cases at St. George's
Hospital, is that the opening of the sac has no effect either on the
death-rate or on the time required for the healing of the wound,
and Mr. Haward expresses his belief that the balance of advan-
tage certainly lies with the operation in which the sac is laid
open. Although the custom at St. George's Hospital is stamped
with very high authority, it may be doubted whether it is
right on such a point to follow anything like a uniform rule of
2:>ractice. Cases of hernia present an endless variety ; every
example therefore demands separate consideration. It seems
inconceivable that in the 181 cases mentioned by Mr. Haward
there were only six in which it was to the patients' advantage
not to open tlie sac, and it is needless to say that in any given
case the welfare of the individual is the only guide that shoidd
be followed. In other words, we must descend from tlie general
414 NOTES.
to the particular. The mortality in the 121 cases at St. George's
was slightly below that in the 100 cases at tlie London Hospital,
but if the cases of umbilical hernia be thrown out of both
tables — and they have no bearing on the present question, for
the sac was opened in all of them — the death-rate for the
inguinal and femoral kinds is 30 per cent, in both series. And
it follows that if any advantage was gained in some cases by
opening the sac, it was counterbalanced in others, for the final
result is the same. Each patient, it would seem, will have the
best chance of recovery secured to liim if his case is carefully con-
sidered on its own individual merits, under tlie guidance of such
rules as are laid down in the text. It may, however, be freely
granted tliat in every doubtful case tlie sac should certainly be
opened.
Note ATF., jpafje 150.
Probably the injury inflicted by acute, or long-continued
strangulation on the vaso-motor system of nerves distributed to
the blood-vessels and muscular wall of the intestine may explain
both the a3dema of the coats of the gut, and the effusion which
takes place into the sac ; and also the paralysis of the strangu-
lated portion which may remain after reduction has been
accomplislied.
Note XV., 'page 150.
In a valuable paper on 'The Surgical Treatment of Perito-
nitis' in the 'St. JWtholomew's Hospital Peports,' vol. ix., 3Ir.
Thomas Smith, referring to tlie good results obtained by
washing out the cavity of the peritoneum in peritonitis follow-
ing ovariotomy, asks wliether the same treatment might not
])i-()ve e(]ually serviceable in some instances in wliich peritonitis
occurs as a complication of strangulated hernia.
Note X IT., j)aije 344.
Tlie Iwo following specimens ani in the ]\Insoum of the
t'ollege of Surgeons :
No 1. A hip-joint, in wliich after llie head and upper part
of the neck of the femur luid been destroyed by \dceration, the
shaft was drawn up, so tliat the remains of the neck rest upon
NOTES.
415
the ilium just above the brim of the acetabulum. The cap-
sular ligament has been removed : the acetabulum is filled with
fibrous tissue. The walls of the femur are very thin, and light.
From a w^omanaged 70. Ten years before her death, she had an
apparently scrofulous affection of Jier hip. Abscesses commu-
nicating with the joint opened in tlie groin, and ultimately the
limb became much everted and shortened. The parts, how-
ever, ultimately healed. The patient died of apoplexy. After
death her lungs and liver were found tuberculous. — Path.
Series^ Gat. Suppleinent I. No. 936.
No. 2. ' The five upper cervical vertebras, and the condyloid
portion of the occipital bone affected at several points wdth
the ulceration (caries). The right transverse process, and both
upper and lower articular surfaces of the same side of the atlas
are entirely destroyed. The disease has also affected the cor-
responding condyle of the occipital bone, and the articular
surface and side of the body of the axis, the right transverse
process, and side of the body of the third and the left occipito-
atlantal articulation. These parts w^ere removed from the body of
the Very Eev. W. Buckland D.D., Dean of Westminster, who
died, set. 73, August 14, 1856. No symptoms manifested them-
selves during life but those attributed to melancholia.' — Loc»
at. No. 3406.
Note XVII., parje 350.
Strong confirmation of these observations has been met with
at the Hospital for Sick Children. The following table com-
piled from the records of fever occurring among the in-patients
is sufficient for the purpose of illustration. The cases are placed
as they stand, entered in different years, in the Wardbook : —
No. of
Case
Sox and
Age
Date of
Admission
1
2
3
4
V. m.
f. '1-9
f. 3
m. 3
m. 2
July 22
Sept. 6
Sept. 3
Jan. 31
5
m. 3-6
Juno 24
6
ni. 9
July 6
7
m. 4-6
Oct. 31
8
m. 4
Juno 16
Nature of Operation
For Cleft pal a to
Woljbed fingers
Necrosed tarsus
I'^itty tumour
Necrosed t;irsus
Ischio rectal abscess
Date of
Operation
July 23
Sept. 8
Sept. 10
Feb. 14
June 30
July 8
Nov. 2
June 16
Date
of
Attack
July
24
Sept.
10
Sept.
11
Feb.
16
June
31
July
0
Nov.
4
June 18
41 6 NOTES.
And ]Mr. Thomas Smitli tells me he has performed
Lithotomy on forty-three children under ten years of age, and of
these seven had scarlatina. In Case 1 : — the eruption appeared
on the day after the operation, and there were rigors, and a
temperatiu'e of 104°'6. Case 2 : — eruption on second day,
followed by general desquamation. Case 3 : — ernption on
second day, death on thirty-first day from albuminuria, and
anasarca. Case 4 : — eruption very soon after operation, followed
by desquamation. Case 5 : — eruption on third day, severe albu-
minuria. Case 6 : — slight eruption very soon after operation,
followed on thirteenth day by general desquamation, and by
severe albuminuria. Case 7 : — eruption on second day, begins
ning at the wound, and spreading over trunk and limbs. This
proportion of seven in forty-three cases is very high, yet the
real proportion was even larger than these figures represent,
for among the thirty-six children tliat escaped there were, as
Mr. Smith remarks, no doubt some who, liaving already had
the disease, were in great part if not completely protected
against a second attack.
It has been questioned wliether tlie affection is true scarlet
fever. In many instances, liowever, it certainly is, for its
features are well marked and cliaracteristic. Of others, which
might be very doubtful if seen as isolated cases, Dr. Gee,
whose authority will be recognised, and wlio has closely studied
the subject, says in his article in ' Keynold's System of Medicine,*
' that the disease really is scarlet fever seems to be proved by the
following observations : first, it occurs in epidemics (of scarla-
tina) : secondly, tliat in a given epidemic a severe case occasion-
ally relieves tlie monotonous recurrence of tlie very mild forms :
tliirdly, that a precisely similar scarlatinilla attacks, in the same
epidemic, ])atients who have not been subjected to operation,
and wlio liave no f>pon sore : and lastly, by way of a veritable
experiment uiu crucis, tliat liowever freely these patients are
exposed to oi'dinary scarlet fever afterwards, they do not con-
tract that diseasr'.' The cases related above illustrate many of
tlie points relied on l)y Dr. (ice. In not a few the attack was
severe and followed by albuminuria : the majority were seen
NOTES. 417
during the prevalence of scarlet fever in town, and almost all, if
not every one, as soon as the illness appeared, were transferred
to a ward used for the treatment of scarlet fever, and which
generally contained recent cases ; yet I believe none of the
patients suffered from any farther contagion. In expressing my
own opinion that the disease is scarlet fever I am conscious of
being strongly biassed by the belief of those in whose sound judg-
ment I place complete reliance ; but I think an independent ex-
amination of the facts could scarcely lead to any other conclusion.
Sir James Paget has mentioned two views as to the expla-
nation of this connection between operations and the appear-
ance of scarlet fever ; and the evidence derived from the cases
related above goes to prove that both are correct, though of
course in different cases. ' That a peculiar liability to contagion
is induced by an operation, and that the poison produces its
specific effects in much less than the usual period of incubation '
seems clear from such cases as the following. A boy (case 4 in
the table) was admitted on January 31. On February 14 he
underwent an operation on a deformed hand, and on the 16th
the rash appeared. No scarlet fever had occurred, so far as his
parents knew, near his residence for some time before he came
into the Hospital, and, indeed, he had been in for a period that
was more than long enough to complete the incubation of the
disease, without showing any symptom of illness. But on the
same day (Feb. 14) on which his operation was performed a
boy, who was admitted into the ward with bronchitis, was
found three hours later with the eruption of scarlet fever.
Again, a child was seized with scarlet fever the day after an
operation had been performed on her mouth. Her mother knew
nothing of any source of previous infection, but the surgeon
who performed the operation was at the time nursing his own
children with the disease. Now it seems nearly certain that
the first child derived the fever, either just before or just after
his operation, from the patient in whom the- rash was just
coming out : and that the second was infected at the very time
from the clothes of the surgeon who performed the operation.
On the other hand, in several instances very careful search has
E E
4i8 NOTES.
failed to discover any source of recent infection ; and in such
the only probable explanation seemed to be that, as Sir James
Paget suggests, the patients ' liad previously imbibed the poison,
but would not have manifested its effects so soon, if at all, un-
less their health had been exhausted or disturbed/
The interval between the operation and the appearance of
the rash has been quite as short as that recorded in the text.
In several the eruption has come out on the next day, and the
period (from twelve to thirty-six hom's, Gree) by which vomiting
and high temperature commonly precede the eruption has been
comparatively seldom distinctly marked.
To anticipate the possible objection that fever may have
been already on tlie point of breaking-out when the operation
was performed, I may state that this source of fallacy has been
carefully borne in mind : it is a standing rule to examine
the temperature, and if it is found in any degree above the
natural standard the operation is invariably postponed.
Scarlet fever apparently stands alone among the eruptive
fevers in its proneness to attack patients immediately after
operations ; for although outbreaks of measles have been
noticed under similar circumstances, their occurrence has been
so rare that they may well be regarded as mere coincidences ; and
the same may be said of chicken pox.
Great help may be gained in the study of this subject from
a very able and valuable paper (in tlie 12tli volume of the
* Obstetrical Society's Transactions ' ) by Dr. Ih'axton Hicks, in
which he discusses the occurrence of scarlet fever immediately
after parturition, witli the purpose of investigating its relation
to puerperal fever. In this essay, and the cases that accompany
it. Dr. Hicks shows : I. That patients are frequently attacked
with scarlet fever after labour. II. That the disorder appears
very speedily — generally within foiu- days. III. That the usual
premonitory symptoms are often absent. IV. Tliat contagion
is in some cases conveyed at the time of labour, in others tliat
it has, so far as can be ascertained, occurred some time
before. V. That in many instances the disorder deviates widely
from the normal type.
INDEX.
-•o«-
ABD
ABDOMEN, condition of, in strangu-
lated hernia, 112
Abdominal pulsating tumour, 237
Abscess, residual ; see Residual abscess
Acupressure, 76
Acute disease, operations during, 20
Acute necrosis, followed by chronic
pyaemia, 161 ; recovery from pyaemia
after, 161
Adhesions formed in joints after long
rest, 97
Age, its influence on operations, 5
Agricultural districts, patients from, 17
Ague, operations during, 20
Ague-fits resembling pysemic rigors, 20
Albuminuria aifecting results of opera-
tions, 39, 56
Amputations for injury and disease com-
pared, 3 ; in the strong and the feeble
contrasted, 3 ; in printing-office boys,
4 ; secondary, 2 1 ; dangerous during
cellular inflammation, 21 ; for com-
pound fracture, 21 ; during acute di-
sease, 21 ; during acute and chronic
pyaemia, 22 ; in the old, 33
Amyloid disease of liver. 29, 403
Anaemia, operations during, 47
Aneurism, mimicry of, 238, 241 ; in
abdominal aorta, 238 ; condition of
vessels, 239 ; rules fordiagnosis of, 240
Angular curvature of the spine in the
old, 224, 415
Ankle, stiffened by involuntary mus-
cular action, 89
Ankylosis treated by bone-setters, 85
Anstie, Dr., on hypochondriasis, referred
to, 269
Antagonism in disease, 389
Antiseptic treatment, Mr. Lister's, 76
Arteries, degeneration of, affecting ope-
rations, 32; heal slowly, 33
Atrophy, reflex, in joint disease, 209
E E ^1
BRI
BACKACHES, 220-224
Baker, Mr., his case of necrosis of
femur, 342
Bandages, tight, over joints often mis-
chievous, 210
Barwell, Mr., on gonorrhoeal rheuma-
tism, 171
Bedrooms, water-closets in, 67
Biceps, slipped tendon of, 86
Billroth on dissection wounds, referred
to, 338
Birkett, Mr., on hernia, 123
Bladder, stammering, 78
Bleeding, its value in strangulated her-
nia estimated, 143
Blizard, Mr., fatal operation by, 65
Bones, disease of, in patients with amy-
loid disease, 29; chiefly affected in
some cases of chronic pyaemia, 165 ;
injury of, followed by neuromimesis,
194; residual abscess in, 316
Bone-setters, treat fractures, disloca-
tions, ankyloses, slipped tendons, 85,
86 ; their manipulations, 84 ; cases
they cure, 84; their results, 99; in
cases of muscular rigidity of joints,
91 ; in sprains, 91 ; treatment of cokl
joints, 93 ; their audacity, 95
Bowels, not to be disturbed after hernin-
operations, 145; condition of, in
strangulated hernia. 111, 112
Boys, amputations in, 4 ; mimicry of
joint-disease in, 203
Breast, operations on, during lactation
to be avoided, 40 ; mimicry of cancer
in, 241 ; neuralgia of, 243 ; neural<:ia
of, associated with gout, 243 ; tumours
of, method of examining, 214
Breathing, its relation to the pulse,
31
Brinton, Dr., liispnper on disease of tlio
oesophagus, 83 .
9
420
INDEX.
BRO
Brodie, Sir B., on hysterical joints, 196 ;
on relaxed, loose joints, 211 ; on
liquor potass?e in cancer, 388
Bronchitis, complicating operations. 34
Brown-Seqnard, Dr., on transmission
of the effects of injuries to oifspring,
363
Budd. Dr., on malignant pustule, 266
Burning soles a sign of gout, 373
Butlin, Mr., case of ankylosis at knee
from long rest, 97
Bursse, imitated by residual abscess, 319
CALAMITIES of surgery. 51; not
always accidents, oo ; rules for
avoiding, 60-64
Callender, Mr., his statistics of amputa-
tions, 4
Cancer, mimicry of, 181, 183, 241 ; in
the breast, 244 ; in the tongue, 244,
245 ; evolution of, 364, 366 ; brought
out by injury, 377 ; its climax in old
age, 380 ; mistaken for scrofula, 380 ;
relieved by liquor potassae, 388; va-
riation of pain in, 389 ; does not
advance pari passu with tuberculosis,
or syphilis, 389
Cancerous persons, operations on, 13
Carbolised catgut ligatures, 76
Carbuncle, ti:eatment by ' doing nothing,'
what tliis means, 252 ; incisions
often fail to stop spreading, or pain
of, or to hasten tlie healing of, 2.34,
256 ; abortion of, 257 ; crucial in-
ci.sion of, its value discussed, 258,
259 ; limited incision often useful,
258 ; high feeding, and .stimulants in,
unnecessary, 259, 260 ; amount of
food required, 261 ; local treatment
of, 262 ; medicines, fresh air, 264 ;
mortality of, 265 ; less fatal now than
when crucial incisions were used, 266 ;
carbuncular inflamnnition of tlio lip,
266; frequently fatal, 267; followed
by pyreniia, 267
Carbuncular inflammation of tlie lip,
267 ; true nature of, 267
C.'ire after operations, 76
Carpus, mimic disease in, 197
Cases, method of recording. 49 ; that
bouo-setters cure, 84
Catgut ligatures, 76
Cathcterisin, need for care in, 43, 57;
dangerous in the old, 43, 47 ; nr>t
rjirely fatal, 69; often miscliievous,
69; followed by chronic pyremia, 166
Caustic, rcmoviil of scjilp-cysts l)y, 70 ;
ti'eatment of luemorrhoid.s with, 71
CON
Cautery, actual, for hsemorrhoids, 71
Chambers, Dr., on invalids, 17
Children, operations on, 5, 18 ; bear
pain ill, 5. 399 ; little liable to pya?mia,
except in acute necrosis, 5 ; amyloid
disease in, 29, 403 ; rigid joints in,
after hurts, 90 ; chronic py;emia in,
170 (note) ; nervous mimicry in,
204; phlebitis in, 309; narcotics
for, 400 ; loss of blood in operations
on, 400 ; risks of operations in, 401
et seq.
Chloride of zinc for wounds, 76
Chloroform in heart disease, 30 ; death
under, 51 ; its use in neuromimesis,
201, 229.
Chorea, diagnosis of, from joint disease,
212.
Chronic pyemia, relations of, to acute,
155, 164; chiefly affecting the l)ones,
165 ; after acute necrosis, 161; affecting
a single tissue, 165 ; uniform method
in, 165; after parturition, 165; fol-
lowing stricture, 166 ; lithotrity, 167;
inflamed inguinal glands, 169; pro-
positions concerning, 170; in chil-
dren, 170 (note); affinities of, 171;
prognosis of, treatment of, 171
Circulation feeble, in nervous mimicry,
188
Cold applications mischievous in nervous
mimicry, 247
Cold-blooded persons, operations on,
18; recover from injury slowly, 395
Colic, preceding strangulated liernia,
107
Constipation, its importance ot'ten over-
rated, 27 ; too profuse action after,
28 ; in neuromimesis, 184
Constitution, the nervous, conij^ared
with that in gout or syphilis, 175;
often inherited, 175; patients who
display it, 175; in neuromimesis,
188
Constitutional diseases, 353 ; import-
ance of lesser signs, 354 ; liealth
characters, compared with mental cha-
racters, 355; meanings of mimes, 356;
inherited constitutional diseases, 356 ;
diathesis, dy.scrasia, 356 ; con.stitu-
tional distiirljance, 356 ; tendencies
to disease, 357 ; their transmission to
offspring, 357; progressive elianges
in, as age advances, tiieir])eciiliarities;
constitutional diseases pervade all
])art8 of the system, 358 ; variation
of, in transmission, 360; illustrations
from gout, scrofula, tS:c. 30 1 ; cvo-
INDEX,
421
CON
lution of diseases, 362 ; variations in
the form of hereditary diseases in dif-
ferent generations, 362 ; relations of
leprosy to keloid, 362 (note) ; Dr.
Fagge's papers on, 362 (note) ; evolu-
tion of disease, 363, transmission of
the effects of injuries to offspring,
Dr. Brown-Sequard's experiments,
363 (note) ; lithic acid diseases in
gouty families, evolution of cancer
from innocent tumours, 364 ; Darwin's
researches, 364 (note) ; evolution of
syphilis, 365 ; relation of syphilis and
scrofula, 365 ; evolution of cancer gout
and tuberculosis, 366 ; evidence of
inheritance difficult to obtain, 367 ;
inherited qualities, not always con-
stitutional, 367 ; mutations of local
and constitutional diseases, 368,
as seen in chronic rheumatic arth-
ritis, 369; lesser signs of constitu-
tional disease, 369; pathognomons
of morbid constitutions, 370; value
of lesser diseases for diagnosis of
constitutions, 372 ; minor signs of
gout, 372 ; of tuberculosis, of scrofula,
373 ; significant groups of disease,
375 ; constitutional defects brought
out by injury, or disease, 376; by
fever, 378 ; by mental trouble, 379 ;
need for careful treatment of slight
injuries, 378: constitutional origin of
fever-sequelae, 379 ; time in constitu-
tional diseases, climax, decrease, re-
vival, 380 ; may be out-lived, 381 ;
nervous and scrofulous constitutions
outlived, not so the gouty, 382 ; ampu-
tations in scrofula, 382 ; late reappear-
ance of sj-philis ; scrofula in the aged,
inveterate form of, 384 ; successions
and combinations, of constitutions,
384 ; scrofula, gout, cancer in succes-
sion, 385 ; methods of life, 385 ;
evidence of constitutional succession,
co-existence, 387, distinct from com-
binations ; antagonism in disease, 389 ;
combinations, 390 ; syphilis with scro-
fula, tuberculosis, or gout, 391 ;
use of mercury, combination of gout
and rheumatism, 393; hybridity in dis-
ease, 393; lesser constitutional con-
ditions, 394 ; cold-blooded persons,
weak constitution, 396 ; long-lived,
short-lived families ; unpunctuality in
constitutions ; delayed puberty ; pre-
vailing death-periods in families, 397
Constitutional peculiarities, tlieir im-
portance in operations, 2
f DIS
Consulting-rooms, private, danger of
operations in, 65
Coughing, painful, in spinal disease, 226
Crimean War, dysentery during, 26
Croup, operations in, 22
Curling, Mr,, on the repair of wounds
in the insane, 407 ; on slipped pero-
neal tendon, 408
C^'st, removal of, fatal result, 65 ; re-
moval by caustic, 70
DAEWIN'S researches on evolution
referred to, 364
Death, fear of, affecting operations, 44 ;
under chloroform, 51
Defaecation, stammering in, 83 ; semen
passed during, 273
Deglutition, stammering in, 82
Delirium trem.ens, operations during,
45 ; after operations, 46 ; treatment
of, 46
Deltoid, wasting of, in diseased shoulder-
joint, 209
Demarquay, M., on slipped tendons, 408
De Morgan, Mr., on the use of chloride
of zinc in wounds, 76
Diarrhoea, operations during, 26 ; pre-
ceding descent of hernise, 26 ; dan-
gerous in children and old people, 27 ;
preceding strangulation of hernise,
107 ; after strangulated hernia, 146
Diet, after strangulated hernia, 146
Dieulafoy on aspiration, 412
Digestion, feeble in old people, affecting
operation, 26
Diphtheria, operations during, 22
Disease, amputations for, 3 ; acute, am-
putations during, 20 ; present treat-
ment of, 143 ; old fashioned treatment
of wounds by bleeding, 1 43 ; evo-
lution, and involution of, 363 ; muta-
tions between local and constitutional,
368 ; bringing out constitutional de-
fects, 376
Dissection, poisons, 321 ; wounds, dan-
gers of, improved treatment of, 321 ;
author's own case, 322 ; mode of in-
oculation ; a fatal case (note) ; na-
ture of the virus, 322 ; acquired im-
munity, 323 ; Dr. AVilks on warts
following, 324 ; loss of immunity
from, 327 ; Dr. Symes Thompson's
case, 327; irritating pus in, 334;
crysipclns following. 334; crisis in
illness following, 335; treatment, 335 ;
complications modified by constitu-
tional peculiarities, 336
422
INDEX,
DOU
Douche, cold, sometimes hurtful. 93
Dreams, in sexual disorders, 28o ; their
relation to emissions, 285 ; mental
treatment of, 287
Drunkards, dangers of operations on,
lo, 56
Dysentery, operations during, 26
Dyspepsia, operations during, 25
EATING, excessive, hurtful for opera-
tions, 16
Elastic knee-caps, often do harm, 210
Elbow-joint, internal derangement of,
87 ; stiffened by involuntary muscular
action, 89
Election, place of, in hypochondriasis,
273
Electricity, for hysterical joints, 95
Embolism in goiity phlebitis, 295
Emissions, 275 ; frequently harmless,
276 ; caiised by irritable spinal mar-
row, 276 ; accompanying symptoms,
277 ; the consequences, not the cause
of nervous disorders, 279
Emphysema, of lungs, affecting opera-
tions, 34 ; over strangulated hernia,109
ICpigastric artery, wound of, in opera-
tions for hernia, 141
Epilepsy, its relations to sexual dis-
orders, 288, 289
Erichsen, 3Ir., on hernia, 123 (note) ;
on damaged intestine in strangulated
hernia, 140; on dissection-wounds, 338
JCrysipelas, operations during, 21; fol-
lowing albuminuria, 56 ; transmuta-
bility of,with pyaemia, referred to, 164
Esmarch's elastic ligature, 76
Estimates, various, of success and fail-
ure, 75
Mther, preferred for operations, 52
(note)
l)xanthemata affecting operations in
children" 401 (note)
JCxcretion, importance of, after opera-
tions, 50
Extensors of fingers, slipped tendons
of, 86
1^"^.\ILURES, various estimates of, 75
- Eat persons, operations on, 14
l*'ayrer, Dr., on opcraticms on native
Indians, 405
I'eet, cold, or painfully hot, in nervous
mimicry, 189
Ecmur, fracture of, f(jl lowed by anky-
losisat knee, from rest, 97 ; swelling of,
in clironic pyaemia, treated witli licjuor
potafe.'^t^, 160; quiet Jiecrosis of, 342
HER
Fergusson, Sir "William, his careful
choice of apparatus for operations, 73
Fever, discovering constitutional dis-
ease, 378 ; sequeltE of, their constitu-
tional origin, 379
Flower, Professor, on a skeleton at
Marbiirg. 206
Food, excess of nitrogenous, hurtful for
operations, 16
Fracture, compound, ampxitation in, 21
fractures treated by bone-setters, 85
Frictions, over injured joints, 94
GALVANISM, in nervous mimicry,
247
Gant, Mr., on constitutional diseases,
375 (note)
Gimbernat's ligament, in femoral her-
nia, 132
Girls, nervous mimicry in, 205, this
promoted by education, 231
Gonorrheal rheumatism, affinities of,
with chronic pysemia, 171
Gout in injm-ed joints, 95 ; combined
wnthneuromimesis, 188 ; evolution of,
366 ; minor signs of, 372 ; brought
out by injury, 377 ; climax in middle
life, 380 ; following scrofula, 386
Gouty persons, ojjcrations on, 12;
phlebitis, see Phlebitis ; constitution
not outlived, 382
Gull, Sir William, on hypochondriasis
referred to, 269
HAMILTON, Dr. Frank, on slipped
biceps-tendon, 409
Ilsemorrhage, its effect on the pulse and
breathing, 32 ; in children, 400
ILemorrhoids, ligature of, sometimes
fatal, 70; treated with caustic, 71;
witli actual cautery, 71
llaward, Mr. "Warrington, on hernia,
123, 413
Health best standard for operations, 2,
5 ; general in neuromimesis, 187
Heart, diseascof, aff"ecting operations, 30
Hernia, strangulated, 101; statistics of
operations, 101 ; grounds for opera-
ting on, 102, ct seq. ; signs of strangu-
lation ; means of reduction, 102 ; pulso
and respiration in, 103, 115; doubt-
ful signs of strangulation, 103 ; their
great importance, 104; local signs;
general symptoms, 104 ; iri'c<lncibility
104; unu.sual size, 104, 107, 108;
liardness of the tumour, 104, 108;
inflanmiation of, or over the sac,
sloughing of integuments over the sac
INDEX,
423
HER
iinassociated with strangiilatiou, 1 Go ;
diagnosis between strangulated and
inflamed, 106; strangulation preceded
by diarrhoea, 107 ; by pain ; presence
of obscure swelling, 109 ; emphy-
semaof integumentsover, 109 ; caution
against overlooking, 110 ; useless ope-
rations on, 110; double, operations
on both, 110 ; local signs, less severe
in the old than in the young. 111;
in old than in recent cases, 111;
omental, signs of strangulation in,
little marked, 111; inaction of the
bowels 111; vomiting a very important
sign, 113, 115 ; aspect of the patient,
116; attempts at reduction, 117;
their method, 117; when improper,
118; irreducible, rule for operating on,
118 ; accessories to reduction, warm
bath, its management, 119; opium,
120 ; enemata, 120 ; chloroform, 121 ;
need for gentleness, 121 ; question of
delay before operating, 123 ; ice, 123 ;
tobacco, posture, cupping, &c,, 12-1 ;
partially reducible, 124, 135 ; reduction
enmassc, 125 ; seat of stricture, 127 ;
opening of the sac, 127, rule for, 128 ;
Lawrence on, 129; incisions in ope-
rations on femoral, inguinal, umbi-
lical, 129; seat of stricture in the
various forms, 130, 134 ; Mr. Luke's
rule for ascertaining this, 130; treat-
ment of the sac, rules for exposing, 131;
partial reduction, 135; omentum re-
maining in the sac after operation; ma-
nagement of its contents, characters
of fluid in, 135; fluid from perito-
neum, 137; treatment of omentum,
137 ; of damaged intestine, 138 ; com-
plications referred to, hydrocele, vari-
cocele, misplaced testis, wounded in-
testine, 140, 154; after-treatment
changed in late years, 142 ; treatment
by bleeding, by purgatives, 143 ; signs
of relief from strangulation, 145;
action of bowels after operation, 145 ;
diet after strangulation ; colic and
vomiting following, 146 ; not relieved
by operation, 148-151 ; conditions,
treatment, 140 ; peritonitis after ope-
ration, 150 ; troubles following opera-
tion, 151 ; acute inflammation of the
sac, symptoms, treatment, 151, 163 ;
inflamed cellular tissue around,
sloughing of scrotum, 154
Hewett, Mr. Prescott. on pya,'mia, 169,
(note)
Key's ligament in femoral hernia, 132
INT
Hilton, Mr., on the temperature of in-
flamed joints, 215 (note)
Hip-joint, internal derangement of, 87 ;
stiffened l»y involuntary muscular
action, 89 ; nerve mimicry in, 197r
209 ; residual abscess after disease
of, 315
Holmes, Mr., on hernia, 413 (note)
Hood, i)r. Wharton, on bone-sotting, 100
Hospitals, provincial, mortality in, 16
Hot spongings in neuromimesis, 246
Houses, unhealthy, operations in, 67
Hutchinson, Mr., on hernia, 411
Hybridity in disease, 393
Hypochondriasis, 173 ; sexual, cha-
racters of, 268, 273 ; dependent on
ignorance of sexual things, 269 ;
semen in the urine generally a fallacy,
270, often only mucus, 271, 272;
' pLice of election,' 273 ; mucus from
urethra, 273 ; varicocele, 274 ; various
terrors, 275 ; likeness to nervous
mimicry, 278 ; most common in men,
278 (note); treatment, 280; ending
in insanity, 280 ; impotence in, 281 ;
varieties of impotence, 281 ; mastur-
bation, 284 ; dreams, 285 ; mental
treatment, 287; relation of insanity
to sexual disorders, 289
IMAGINxVTION in nervous mimicry,
184
Imitation provoking nervous mimicry,
194
Impotence, not due to varicocele, 68 ;
definition of, 281 ; various causes of.
281 ; often imaginary, 282
India, natives of, their tolerance of in-
jury, 17, 405
Inflammation, cellular, amputations
during, 21
Inflamed parts, danger of operations on,
65
Inguinal glands, suppuration in, fol-
lowed by chronic pyjemia, 169
Inheritance in nervous mimicry, ] 85
Injury, amputations for, 3 ; provoking
neuromimesis, 198, 204 ; bringing out
constitutional defects, gout, &c., 376
Insane persons, operations on, 45, 407 ;
not generally subject to nervous mi-
micry, 184
Insanity following operations, 46 ; in
connection -with nervous mimicry,
185 ; its relation to sexual disorders,
280, 291
Integuments slougliing over hernia',
105
424
INDEX.
Intemperate, the, dangers of operations
on, 14
Internal derangement of joints, knee,
jaw, elLow, hip, 87
Intestine, management of, in hernia
operations, 138; its characters when
long strangulated, 138; woimded in
hernia-operations, 140 ; powerless
after stranguLition, 151, 414 ; rupture
of, after operation, 151
Intestinal distension in nervous mi-
micry, 184
Invalids, operations on, 17
Iodides, in treatment of nervous mimic-
ry, 248
Iron in nervous mimicry, 248
JAW-JOINT, internal derangement of,
87 ; locked, treatment of, 88
Jenner, Edward, his gouty eczema, 373
Joints, disease of, associated with amy-
loid liver, &c., 29,403; injured, treated
l)y bone-setters, 84 ; internal derange-
ment of, 87 ; stiff, from involuntary
muscular action, 88 ; rigid, after hurts
in children, 90; shamming disease of,
91 ; injured, treated by cold douche,
93 ; by shampooing, warmth, and
frictions, 94 ; rules for exercise, 94 ;
habitually cold, 93 ; treated by too
long rest, 93, 9G ; over-sensitive after
rest, 93, 97 ; constitutional treatment
of, 95 ; hysteria)!, cured by ]Mi'smer-
ism, 95 ; ankylosed, after long rest,
07 ; gouty, strumous, hysterical, their
movement after injury, 98 ; frequency
of mimic disease of, 181, 187: niiniic
disease," of, in children, 187, 204;
mimicry of disease after injury, 194 ;
disease of, mistaken for mimicry, 19G ;
wasting of limbs in, 208, 210; not
deformed, simply by posture, 200;
laxity of, 211 ; disease of, imitated
by chorea, 212; residual abscess in,
213, 314 ; temperature of diseased,
215; Mr. JHlton on, 215; relapsing
inflammation of, 310; loose bodies
in produced by quiet necrosis, 313
KELOID, its relations to leprosy, 3G2
(note)
Kidneys, disease of, aflfecf ing opcraf ions,
.'{9, 403; lithotomy ami lithofrity
in, 41
Kncejoint, internal derangement of:
signs of, 87 ; stift'ened, by muscular
MEN
contraction, 89 ; ankylosed, after long
rest, 97; nervous mimicry in, 197
LALLEMAND on spermatorrhoea, his
account an exaggeration. 288
Laurie, Prof, on phlebitis, 307
Lawrence, Sir AV., on hernia, 123 (note),
129, 140
Leprosy, its reLition to keloid, 362
(note); its distant inheritance, 367
Life, various rates of, 397
Ligature, carbolised catgut, 76 ; Es-
march's elastic, 76
Limbs their posture in neuromimesis,
202; wasting, in joint disease, 208
Limping in cases of damaged joints, in
neuromimesis, 211
Lip, carbuncAilar inflammation of, 266 ;
thisfrequentlv fatal, 267 ; true nature
of, 267 '
Liquor potassa?, in chronic pycemia,
166, 171 ; in cancer, 388
Lister, Mr., his antiseptic method, 76
Lithic acid diathesis in neuromimesis,
248
Lithotomy in those with kidney disease,
41 ; followed by chronic pyjemia, 159
Lithotrity, in those with kidney disease,
41 ; followed by chronic pytemia, 167
Liver, disease of, affecting operations,
29, 403
Local disease, operations in presence of,
24
Locality in nervous mimicry, 195
liocked-joint, treatment of, 87
Long bones, residual abscess in, 316
Loosi* eartilages in joints, signs of, 87
Ludlow, 3[r. Hiirvev, on malignant pus-
tule, 266
Luke, 3Ir., on the seat of stricture in
hernia, 130
Lupus exedens in septum nasi, and
otlier parts, 375
MALIGNANT pustule, 266
Mammary gland, method of ex-
amining. 244
IMania, religious, followingoperations, 47
Masrurbation, mischiefs following, 28-1,
289 ; relations to insanity, 289
.Maturity, delayed, 397
iNleat, excess of, hurtful for operations, !(►
Melanelioly, 173
.Menst i-uation, operations during, 48
."Mental distress, a cause of nervous
mimii'ry. 192 ; bringing out constitu-
tional defects, 379
IXDEX.
MES
Mesmerism, in hysterical joints. 95
Metastasis, in gouty phlebitis, 294
Mimicry of disease in children, 182, 187
Missisquoi water in cancer, 388
Mucus, vesical, mistaken for sperma-
torrhoea, 272
Muscular rigidity of joints, treatment
of, 89
Muscles, wasted by pressure, 210 ; en-
larged, after phlebitis, 307
NARCOTICS, in nervous mimicry,
246 ; use of, in children. 400
Ts ecrosis, acute, in children, followed by
pyaemia, 5 ; quiet, 339 ; of the femur,
342 ; without evidence of inflamma-
tion, 342 ; circumstances attending,
343 ; pathology of, diagnosis, 343
Nervous mimicry of organic disease.
172 ; aggravating trivial disease, 172;
diagnosis of, its relation to hysteria,
l7o; characters of pain in, 176;
painful sense of fatigue in, 1 77, 224 ;
does not produce real disease, de-
ranged circulation in, 177; flushings
and pallor in, 178; mental state in;
egotism, want of will in, 180 ; belief
in mesmerism, and spiritualism, 181 ;
of joint disease, 181, 196, 204; of
spine disease, 181, 187, 22u ; of can-
cer, 181, 241 ; noi" always mental,
182, 186; intestinal distension, con-
stipation, condition of spinal and
ganglionic nervous systems in, 184,
189; not common in the insane;
effect of imagination in producing,
184: inheritance of; its connection
with insanity; with emotional and
convulsive hysteria, I80; with neu-
ralgia, 185, 243 ; with paraplegia
and epileps}', 185 ; importance of
family history in diagnosis, 186 ; in-
fluence of age, sex, and culture, 187 ;
in the gouty, tuberculous, scrofulous,
187, 188 ; feeble circidation in, 188 ;
cold or hot feet in, 189; nutrition
of parts in, 190; temperature in,
190, 191, 218; following fever, 190;
uterine and ovarian functions in, 191;
exciting causes of, 192, 197 ; of stone
after Napoleon's death, 194 ; after
injury of bones or joints, 194, 204;
locality in, 195 ; a constitutional con-
dition, 195; diagnosis of, 198; imi-
tating inflammation, 198 ; pain in,
198; chlorofoi'ni, its value for <liag-
iiosis, 201, 204, 237 ; rigidity of limbs
OPE
in ; posture in, 202, 204 ; inconsis-
tency of symptoms, 203 ; does not
distort joints, 205 ; swellings or sen-
sations of swellings of joints in, 213 ;
temperature of joints in, 215 ; para-
plegia in, 231; of tumours, 233;
diagnosis of, 236 ; abdominal pul-
sating tumour, 237 ; of aneurism in
abdomen, 237, 238; of subclavian ; of
innominate, 238 ; condition of vessels
in, 239 ; neuralgia of the breast, 241,
244 ; mimicry of cancer of tongue,
244, 245 ; treatment of mimicry as
to [a) local symptoms ; (Ji) con-
stitutional state ; (<?) nervous consti-
tution, 245, 251 ; use of narcotics in;
warmth, hot spongings, &:c., 246 ;
cold, and local bleeding do harm ;
rest after exercise, galvanism, 247 ;
treatment by means directed against
constitutional defects, as gout, scro-
fula, &c., 248 ; food, stimulants, &c.,
249 ; judicious education in, 251
Neuralgia, amputations in former times
for, 382
Neuromimesis. 8cc Nervous mimicry
Nitrogenous food, excess of, hurtful for
operations, 16
Nitrous oxyde for anaesthesia, 52 (note)
Nocturnal emissions. &ce Emissions
Nutrition unaffected in nervous mimicry,
190
OBTURATOR artery mounded in
hernia-operations, 141
CEsophngus stammering, its diagnosis, 82
Old persons, operations generally dan-
gerous in, 5, 33 ; differ in their powers
of bearing operations, 6, 7 ; need
special management after, 8
Omentum, treatment of, in strangulated
hernia, 137
Operations, the various risks of, 1 ;
standards of health for, 2. 5 ; in young
children, dangerous by shock, 4 ; pa-
tients who bear them best, 5 ; in-
flnence of age on, 5 ; dangerous in
old people, 5, 33 ; on the scrofulous, 8
on the syphilitic, 11; during acute
and chronic rheumatism. 12 ; on the
gouty, 12; the cancerous, 13; tho
plethoric, 13; th(; over fat. 14; the
intemperate, 14, 15 ; on teetotallers,
16; on large eaters, 16; on persons
fi-om the country, natives of India,
invalids, 17 ; on thi.' 'cold-blooded,'
18; the nervous, 19 ; in acute disease,
20 ; during erysipelas, 21 ; in pyoemia
426
INDEX.
OPE
22 ; diplitlieria, croup, peritonitis, 22 ;
in dyspepsia ; vomiting after, 2.5; dur-
ing dysentery, diarrlicea, 26; state
of bowels after, 28 ; aifected by
disease of liver, 29 ; of heart, 30 ; on
those with quick or slow pulse, 31 ;
affected by disease of arteries and
veins, 33 ; by chronic bronchitis and
emphysema, 34 ; by phthisis, 35 ; by
kidney disease, 39 ; by disease of the
nervous sj'stem, 44 ; fear of death in,
44; capacity for sleep after, 44 ; on
the insane; during delirium tremens,
45 ; followed b}' insanity, 46 ; during
anaemia, 47 ; during menstruation ;
during pregnancy, 48 ; daring lacta-
tion, 49 ; on the breast, during lacta-
tion, dangerous, 49; minor operations
sometimes fatal, 54 ; cases, 54. 59 ;
rules for, 59, 73; in consulting
rooms, 65 ; dangerous on inflamed
parts, 65 ; in unhealthy rooms, 67 ;
never to be done unless essential, 68 ;
bloodless, to l)e chosen, if possible,
70 ; care in the last stages of, 71 ;
oversights during; well-chosen ap-
pliances for, 73 ; diminished mortality
after, 76
Opium, its value in children, 400
Ovarian functions in nervous mimicrv,
191
Oxalic diathesis in ncuromimesis, 248
Ozena in scrofula, 374
PAIN ill borne by children, 5, 399 ;
ill nervous mimicry, 198; with
stiffness in joints, 202
Talms, burning, a sign of gout, 373
Paralysis,r9lationtosexualdisorders,288
Parturition followed by chronic ])y;cmia,
165
Patients best fitted for operatif)ns, 5
S'caslee, I)r.,oii operations on blacks, 406
}\'lvis, mimic disease of, 187
Perforation of intestine after liernia-
o))erations, 161
Peritonitis, operations during, 22 ; after
hernia-operations, 151 ; forms of,
sthenic, asthenic, their resjx'ct ivu
treatment, 152
Peroneus, displacement of its tendo)!, 80,
408
.Pharynx, granular, in tuberculosis, .'!71
Phimosis, o])('iMtions for, 68
J'li lei litis. o])erationH during, 33 ; gonty
and other forms, 202, 293 ; characters
of gouty variety, 294; this often metas-
tatic and symmitrioal, synipl'uns of,
EES
294; most common in lower limbs
and in superficial veins, 294 ; dan-
gerous })y embolism, 295 ; often
liereditary, 297; treatment, 297; phle-
bitis in branches of the venae cava?,
298 ; in blood poisoning, 302 ; often
recurring, 304 ; affecting a portion of
a single vein, 305 ; followed hy en-
largement of muscles, 307; following
typlius, 307 ; in acute pyaemia, 308 ;
after typhoid, 309 ; in young children,
309
Plethora affecting operations, 13
Popliteus, slipping tendon of, 86
Posture of limbs in ncuromimesis. 202
Power, Mr. K., on disease of oesophagus
(case), 83
Pregnancy, operations during, 48
Pressure causing muscular atrophy, 210
Printing-office boys, amputations in, 4
Psoas muscles, residual abscesses in, 313
Puberty, delayed, 397
Puerperal fever, its relation to pyaemia,
164
Pulse, rate of. in relation to operations,
31, 82; ratio to breathing, 31; has-
tened by haemorrhage, 32 ; in stran-
gulated hernia, 103, 115; compared
with breathing, and temperature in
nervous mimicry. 189
Purgative^, in their relation to stran-
gulated hernia. 143
Pj'aemia, rare in children, except in
acute necrosis, 5 ; simulated by egue-
fits, 20 ; amput^itions during, 22 ;
after operation for varicocele, 69 ;
chronic, its relation to acute, 155;
course of, 156 ; distinct from hectic,
156 ; after ligature of subclavian
artery, 157; after lithotomy, 159;
not rarely survived ; after acute ne-
crosis, 161 ; contrasted with specific
fevers, 164 ; its relalionsto erysipelas,
164 ; chronic, in urinary disease, after
catheterism, 166; followed by acute
phlebitis. 308
Pyaemial abscesses after ligature of
Ineniorrhoids, 70
Q
rilOT necrosis; iSfc Necrosis.
T)A])IIS, fracture of, stiff hand after,
t 98
Kectiim. residual abscess near, 319
Keflex atrophy in joint disease, 20!)
]{esidual abscess, 310; in spinal disease,
311; injointdiseasc, 314;inlongbone>«,
INDEX,
427
RES
316; by the rectum, 319; imitating
bursse and tumours, 319 ; treatment,
prognosis, 320
Respiration, ratio to pulse in operations,
31 ; retarded by haemorrhage, 32 ;
in stranguLated hernia, 103, 115
Besponsibilities in operations, 75
East of injured joints, too long con-
tinued, 93, 96, 97
Eetention of urine from stammering
urinary organs, 80
Kheumatism, operations during, 12 ;
in injured joints. 95 ; gonorrhceal, its
affinities with chronic pyaemia, 171
Eibs fixed in spinal disease, 226
Eigidity of limbs in nervous mimicry,
202
Eigors depending on ague-fits, 20
Eisks of operations, the various, 1
a AVOEY, Mr., on the treatment of pa-
O tients before operations, 404
Scalp cysts, operations on, sometimes
fatal, 70
Scapulae, irregularities of, generally un-
important, 230
Scarlet fever, after operations, 349, 415;
characters of, 350, 416; relations to
operations, 351 ; fatal cases follow-
ing operations, 353
Scrofula, aggravated by operations, 9 ;
operations in, 8, 11; senile, 344;
seats of election of, 344 ; characters
of, 345 ; diagnosis of from gout, 345 ;
from cancer, 346 ; treatment of, 347 ;
minor signs of, 373 ; brought out by
injury, 377 ; climax in early life,
380; mistaken for cancer, 381 ; results
of amputations in, 382; re-appearance
of, in the aged, 383 ; this form in-
veterate, 384 ; followed by gout or
cancer, 385
Scrotum, sloughing of, after hernia-
operations, 153
Semen, rarel}' found in urine, 270 ; cir-
cumstances under which it is present,
271 ; passed during defaecation, 273
Senile scrofula, .sec Scrofula.
Septum nasi, perforating ulcer of, 374
Sex in nervous mimicry, 187.
Sexual organs, relation to nervous mimi-
cry and hysteria, 192; sexual hypo-
chondriasis, sec Hypochondriasis :
functions, partial ignorance of, in
civilised races, 269 ; sexual disorders
a cause of hypochondriasis, 270 ;
dreams in, 285 ; consequences of
these disorders often exaggerated, 288
STA
Shampooing of injured joints, 94
Shock, danger of in operations on young
children, 5
Shoulder, operation on, followed by
pyaemia, 52 : stiffened ])y involuntary
nmscular action, 89
Skeleton at Marburg, 206
Sleep, capacity for, value of, after opera-
tions, 44 ; its effect on stiff joints in
children, 90
Slipped tendons treated by bone-setters,
86
Smith, Mr. Thomas, on hernia, 414 ; on
scarlet- fever after operations, 416
Sneezing, painful in spinal disease, 226
Soden, Mr., his case of slipped biceps-
tendon, 86, 409
Soles, burning, a sign of gout, 373
Spermatorrhoea, so-called, 272, 277
Spinal irritation in hypochondriasis,
277 ; treatment of, 280 ; its connection
with emissions, 289
Spinal disease followed by residual
abscess, 311
Spine, stiffened by involuntary muscular
action, 89 ; aching, cracking, 99 ; scro-
fulous disease in the old, 344 ; mimic
disease of, 181, 187; symptoms of,
220 ; spine-aches, 220, 224 ; pain as
a symptom of disease in, 221, 223;
tenderness of, 221 ; pain in, with
nausea or shivering, 222 ; curvature
of, often painless, 223 ; lateral curva-
ture of in the old, 223 ; angxilar
curvature of in the old, symptoms of,
224 ; sprains of, 225 ; symptoms of
disease in, diminished mobility of
ribs, pain on coughing, or sneezing,
&c , 226 ; weakness of, 227 ; shape
of, as a symptom of disease, 228 ; im-
itated by nervous mimicry, 229 ; la-
teral curvature imitated by disorderly
muscular action, 220 ; oblique posture
without curvature, 229 ; mimic para-
plegia, 231
Sprains, treated by bone-setters ; move-
ments in; these sometimes mischie-
vous, 91 ; 'old sprains,' a term in-
cluding various conditions, 93
Stammering, causes of, 77 ; with speech-
organs, 77 ; with urinary organs, 78 ;
with urethra, 79 ; family relations in,
80 ; does not produce real disease, 80 ;
associated with various nervous dis-
orders, 80 ; in deglutition ; with oeso-
phagus, 82 ; in defaecation, 83
Standards of health for operations,
428
INDEX
STO
Stone, mimicry of symptoms after Na
poleon's death, 19-i
Strangulation importance of, cloubtfiil
signs of, in hernia, 103
Stricture, medical treatment of, 42, 69 ;
with kidney disease, 42 ; depending
on swelling of the mucous membrane
of the urethra, 42
String-halt, 212
Struma in injured joints, 95
Subclavian artery, ligature of, followed
by chronic pyaemia, 157
Success in surgery, various estimates of,
75
Suckl i ug, operati ons performed during,49
Surgery, calamities of, 51
Sutures, silver, an improvement in prac-
tice, 76
Synovial fringes nipped, symptoms fol-
lowing, 87
Swelling as a sign of joint disease, 213
Symmetry in gouty phlebitis, 294
S}'philitic persons, operations on, 11 ;
eruption appearing after a fright, 380
Syphilis, reappearance of, after long in-
tervals, 383 ; combined with scrofula,
tul)erculous gout ; caution in the use
of mercury for, 392 ; secondary, con-
tinuous between its outbreaks, 165
TABLES, value of, for estimating risks
of operations, 2
Tarsus, stiif after injury, 98 ; position
of foot after, 98 ; nervous mimicry of
disease in, 197
Tcale, Mr., on hernia, 123 (note); on
necrosis of cartilage. 343
Teetotallers, operations on, 15
Temperature in nervous mimicr}-, 190;
in joint disease, 218; affected by
fatigue. 218; during convalescence,
190, 218
Testis, wasting of, not due to varicocele,
68 ; misplaced, complicating hernia,
140 ; undescended complicating stran-
gulated liernia, 154; relapsing in-
fliimmation of, 310
Thompson. \)r. Symes, his illness after ;i
dissect ion-wound, 327
Tibia, acute necrosis of, followed by
chronic pyjemia, 165
Tongue, mimicry of cancer in, 244
WIL
Torsion of arteries, 76
Tuberculosis, with nervous mimicry,
188; evolution of, 366; evidence of
inheritance, 366 ; minor signs of, 373
Tumours, nervous mimicry of, 233 ;
phantom, characters of, 233 ; diag-
nosis of, 236 ; pulsating in abdomen,
237 ; imitated by residual absce.ss, 319
Tj-phoid fever, followed by phlebitis,
309 ; sequeljfi of, 379
Typhus, followed by phlebitis, 307
TTLCER of septum nasi in tuberculosis,
U 374
Urethra stammering, 79
Urinary fever, 41 ; urinary organs,
stammering in, 78 ; becoming ' ner-
vous' when diseased, 80 ; disease of,
followed by chronic pyaemia, 166
Urine, low specific gravity of, in the old,
44 ; containing semen, explanation
concerning, 271
Uterine functions, in nervous mimicr}-,
191
YARICOCELE does not cause im-
potence, 68 ; or wasting of testis,
68, 274 ; risks in operations for cure
of, 69 ; pyaemia following operations
for, 69 ; seldom requiring operations,
69; complicating hernia, 140; with
strangulated hernia, 154; associated
with hypochondriasis, 274 ; seldom
really mischievous, 274 ; disappear-
ing after marriage, 275
Venae eavae, phlebitis in branches of, 298
Veins, disease of, affecting operations, 33
Vomiting after operations, 25 ; its great
importance in strangulated hernia,
113; its characters in, 115; after
hernia-operations, 146
WAIIMTII, in the treatment of hurt
joint-s 94
Warts on the face often best removed
by caustic, 71
Wasting of limbs in joint disease. 209 ;
abcmt joints, produced by pressure,
210
Water-closets in bedrooms, 67
West, Dr., on narcotics for children, 400
AVilks, Dr.. on dissection wounds, 324
Si'idtiixco-jdc A: Co., I'riiiUrs, NeiC'Street Square, London.
March, 1S76.
Works on
MEDICINE, SURGERY,
AND
GENERAL SCIENCE,
PUBLISHED BY
MESSRS. LONGMANS, GREEN, AND CO.,
PATERNOSTER ROW, LONDON.
§.nafomir, Surgcrg, anir ^Ij^siologir*
^HE SCIENCE AND ART OF SURGERY;
Being a Treatise on Surgical Injuries, Diseases, and Operations. By John
Eric Erichsen, Senior Surgeon to University College Hospital, and
Professor of Clinical Surgery in University College, London. Sixth
Edition, thoroughly revised and enlarged ; Illustrated by 712 Engravings
on Wood. 2 vols. 8vo, price 32J'.
.^ SYSTEM OF SURGERY,
Theoretical and Practical, in Treatises by various Authors. Edited by
Timothy Holmes, M.A., Surgeon and Lecturer on Surgery, St. George's
Hospital. Second Edition, thoroughly revised, with numerous Woodcuts,
Lithographs, and Chromolithographs ; in all 472 Illustrations. In Five
Volumes, 8vo, price One Guinea each.
*^* Each Volume may be had separately, as follows : —
Vol. I., price 21s., comprises all the articles on General Pathology
contained in the First Volume of the previous Edition down to the end
of "Collapse," with the addition of Mr. Croft's essay on Hectic and
Traumatic Fever and the After-Treatment of Operations, which formed
part of the Appendix to the previous Edition.
Vol. II., price 21s., comprises all the Treatises in the previous Edition
relating to General and Special Injuries.
Vol. III., price 21s. — Diseases of the Eye and Ear, of the Organs of
Circulation, Muscles, and Bones.
Vol. IV., price 21s. — Diseases of the Organs of Locomotion, of Inner-
vation, of Digestion, of Respiration, and of the Urinary Organs.
^ Vol. v., price 21s. — Diseases of the Genital Organs, of the Breast, Thyroid
Gland, and Skin ; Operative Surgery ; Appendix of Miscellaneous
Subjects ; with a General Alphabetical Index to the whole Work, and a
List of the Authors.
QUAIN'S ELEMENTS OF ANATOMY.
^ The Eighth Edition. Re-edited by William Sharpey, M.D., LL.D.,
F. R. S., L. & E. Emeritus Professor of Anatomy and Physiology in
University College, London; Allex Thomson, M.D., LL.D., F.R.S.,
L. & E., Professor of Anatomy in the University of Glasgow ; and Edward
Albert Schafer, Assistant Professor of Physiology in University College,
London. Illustrated by upwards of 950 Engravings on Wood. 2 vols. 8vo,
price 32^.
In the present Edition the distribution of the matter between the two voUimes has been in some
respects altered : and it is believed that the use of the book by students will be facilitated by the
change. The First Volume consists of the Special or Descriptive Anatomy of the Bones, Joints,
Muscles, Vessels, and Nerves. It also includes the subject of Surgical Anatomy, which was
formerly treated of in a distinct chapter, originally written in the previous Editions. The whole
of this volume has been edited by Dr. Thomson, in association with Mr. David N. Knox, M.B.
Demonstrator of Anatomy in the University of Glasgow, and assisted by Mr. H. Clarke in
the description of the Bloodvessels, and by Dr. Gowers in that of the Cranial Nerves.
In the Second Volume the section on General Anatomy and the chapters on the Heart, the
Respiratory, Vocal, Digestive, and Urinary Organs, and the Organs of the Senses, have been
revised throughout, and in certain parts re-written by Dr. Shakpev, in association with Mr.
Schafer, by whom the task has in large measure been performed.
A considerable number of new Figures have been introduced into the present Edition, some
having been substituted for former ones now withdrawn, others added as new Illustrations. They
are partly from original drawings, and partly electrotype cojjies of figures in other published works.
^NATOMY, DESCRIPTIVE AND SURGICAL.
By Henry Gray, F.R.S,, late Lecturer on Anatomy at St. George's
Hospital. With 411 large Woodcut Illustrations; those in the First
Edition after Original Drawings by Dr. Carter, from Dissections made
by the Author and Dr. Carter ; the additional Drawings in the Second
and subsequent Editions by Dr. Westmacott. Seventh Edition, by
T. Holmes, ALA., Surgeon to St. George's Hospital ; with an Introduction
on General Anatomy and Development by the Editor. Royal 8vo, 28j-.
*«* The Seventh Edition has received a most careful revision both of the text and of the
sections on Visceral Anatomy ; and the section on the Anatomy of the Kidney has been entirely
re-written by Mr. E. J. Simtta, late Demonstrator of Anatomy at the School of St. George's
Hospital. The new Illustrations incorporated in this edition are from original drawings by Dr.
Klein.
^^yK/^ /\/"v./vr\ /^/■\./\,r\/\/\y-v/-vy>^\.
^ABLETS OF ANATOMY AND PHYSIOLOGY.
By Thomas Cooke, F, R.C.S., Senior Assistant-Surgeon to, and Demon-
strator of Anatomy at, the Westminster Hospital. Crown 8vo.
Bones of Skull (2nd Thousand) M.
liones of Face (2nd Thousand) M.
lioncs of Trunk M.
Hones of Upper Linih M.
Hones of Lower Limb &/.
Toints and Li(^aments ^.
Muscles <yf.
Arteries of Head and Neck
(^nd Thousand) Ccf.
Arteries of Limbs (3rd Thou-
sand) 6ci.
Nerve Centres gd.
Cranial Nerves (ind Thousand,
enlarL'cd) tyf.
Synipatnctic^Nervcs 6tf.
Respiratory Organs M.
Male Genito-Urinary Or^,'ans M.
Dij;cstivc Orjjans M.
Peritoneum and Abdominal
Glands 6tl,
Circulation, Respiration, Ani-
mal Heat (3rd Thousand, re-
vised and corrected) .... IS. Cxf.
Digestion. Ai)sorption 9a'.
Development (Gen. Devt. of
Hmbryo) 6d.
Development of Organs is.
Comijarative Anatomy (Ei^^ht
Tablets on) is.
Ear (ind Eye (3rd Thousand)., is. Chronology of Generation (a
Surgical Anatomy grf. large Tableau 3 ft. square) . . Ctf.
OTHER TABLETS arc in the Press. TABLETS ON SURGERY will appear shortly.
/\.rv/>_/-v>-w
OUTLINES OF PHYSIOLOGY, HUMAN AND
COMPARATIVE.
V>y John Marshall, F.R.S. , Professor of Surgery in University
College, London; Surgeon to the University College Hospital. With
122 Woodcut Illustrations. 2 vols, crown 8vo, 32^.
(COMPARATIVE ANATOMY AND PHYSIO-
LOGY OF THE VERTEBRATE ANIMALS.
By Richard Owen, F.R.S., Superintendent of the Nat. Hist. Depart-
ments, British Museum. 3 vols. 8vo, with 1,472 WoodcutSj 73^-. 6d.
Vol. I. Fishes and Reptiles, with 452 Woodcuts, 2is.
Vol. II. Warm-blooded Vertebrates, with 406 Woodcuts, 2ij.
Vol. III. Manunalia^ including Man, with 614 Woodcuts, 2>'^s. 6d.
T ECTURES ON THE COMPARATIVE ANATOMY
AND PHYSIOLOGY OF THE INVERTEBRATE ANIMALS.
Delivered at the Royal College of Surgeons. By the same Author. Second
Edition, revised, with 235 Woodcuts. 8vo, 21s.
H
EALTH IN THE HOUSE.
Twenty-five Lectures on Elementary Physiology in its application to the
Daily Wants of Man and Animals. By Mrs. C. M. Buckton, Member
of the Leeds School Board. New and cheaper Edition (being the Sixth),
thoroughly revised ; with 41 Woodcuts and Diagrams. Small 8vo,
price 2s,
' We most cordially recommend this admirable books of its kind ever written. We have seldom
book to all who are interested in sanitary re- read so admirable a series of lectures on elemen-
form, and to the wives of clergymen and others tary physiology and the laws of health.' — Man-
specially interested in the welfare of the poor.' Chester Examijier.
—Acadetny. ' An admirable book for teachers and pupiU
'Mrs. Buckton's book is one of the best teachers.' — School Board Chronicle.
T ECTURES ON THE PRINCIPLES AND
PRACTICE OF PHYSIC,
Delivered at King's College, London, by Sir Thomas Watson, Bart.,
M.D., F.R.S., Hon. LL.B, Cantab., Hon. D.C.L. Oxon., &c., Physician -
in-Ordinary to the Queen. Fifth Edition, revised and enlarged, with two
Plates. 2 vols. 8vo, price 36^-.
QLINICAL LECTURES AND ESSAYS.
By Sir James Paget, Bart, F.R.S., D.C.L. Oxon., LL.D. Cantab.,
&c., Serjeant-Surgeon Extraordinary to the Queen, Surgeon to the Prince
of Wales, Consulting- Surgeon to St. Bartholomew's Hospital. Edited by
F. Howard Marsh, Assistant-Surgeon to St. Bartholomew's Hospital.
8vo, 15^-.
o
N HOSPITALISM AND THE CAUSES OF
DEATH AFTER OPERATIONS.
By John Eric Erichsen, Senior Surgeon to University College
Hospital, and Professor of Clinical Surgery in University College. Crown
8vo, price y. (>d.
WORKS ON MEDICINE, SURGERY, (s-c.
EXAMINATION QUESTIONS IN ANATOMY,
PHYSIOLOGY, BOTANY, ^lATERIA MEDICA, SURGERY,
MEDICINE, MIDWIFERY, AND STATE-MEDICINE.
Arranged by H. A. Husband, M.B., M.C., M.R.C.S., L.S.A., &c.
Second Edition, revised and augmented. 32mo, price 4J-. 6^/.
* *«.* Since the last edition was published Examinations in Statk-Mkdicine have been instituted;
and the QubstiOXs asked under this head on Epidemics, Law, Hygiene, Engineering, 8:c. are
now added.
^ DICTIONARY OF MEDICINE.
Edited by Richard Qtaix, M.D., F.R.S., Fellow of the Royal
College of Physicians, and Physician to the Hospital for Diseases of the
Chest at Bronipton ; assisted by numerous Eminent Writers. In One
Volume, 8vo. . [^Preparing for publication.
*\^f\r\/\/\/\/\/\r>'_/\f\f\r\r\f\r\r\r\r\/\r\f\r\/^
(COPLAND'S DICTIONARY OF PRACTICAL
MEDICINE :
Comprising Special Pathology, the Principles of Therapeutics, the Nature
and Treatment of Diseases, Alorbid Structures, and the Disorders especi-
ally Incidental to Climates, to Races, to Sex, and to the Epochs of Eife ;
with an Appendix of Approved Formulae. Abridged from the larger
work by the Author, assisted by J. C. Copland, M.R.C.S. 8vo, 36J.
^HE SENSES AND THE INTELLECT.
By Alexander Bain, LL.D., Professor of Logic in the University of
Aberdeen. Third Edition, with numerous Emendations, and a Review of
Darwin on Expression as a Postscript. 8vo, i<^s.
'HE EMOTIONS AND THE WILL.
By the same vVuthor. 'i'hird Edition, thoroughly revised, and in great part
re-written. 8vo, price \^s.
]y[ENTAL AND MORAL SCIENCE:
A Compendium of Psychology and Ethics. By the same Author. Third
Edition. Crown 8vo, los. 6d. 7o be had also in Two Parts : —
Part I., Mental Science, price 6s. 6d. ; Part II., Moral Science, price 4^. 6d.
LOGIC, DEDUCTIVE AND INDUCTIVE.
By the same Author. In Two Parts, crown 8vo, price io.i-. 6d. Each
Part may be had sejiarately : —
Part I., Deduction, price \s. ; Pari' II., Induction, price ds. 6d.
T
HE HISTORY OF PHILOSOPHY FROM
THALES TO COMTE.
By George Henry Lewes. Fourth Edition, re-written and greatly
enlarged. 2 vols. 8vo, jirice 32 j.
'Mr. Lewf.s's "History of Philosophy," in
its present shape, stands alone in English
literature. Whatever nuiy be thouglit of the
views which it is its author's object to pro-
mote, his book is the most trustworthy, the
clearest, the liveliest, and the most intelligent
exposition of the views of the various j)hilo-
sophers of whom it treats which is to be found | tually.' — Pall AJ all Gazette.
in the English language. If he had written
nothing else, these two volumes would be quite
enough to give him a high and a permanent
place in English literature. Apart, however,
from their literary merit, they have an inde-
pendent value. They are an argument as well
as a history ; an argument which it would rc-
(piirc the rnrost (jualificaiions to answer efTcc-
PUBLISHED BY MESSRS. LONGMANS, GREEN, &- CO.
7"HE SECRET OF HEGEL:
Being the Hegelian System in Origin, Principle, Form, and Matter. By
James Hutchison Stirling, F.R.C.S. & LL.D, Edin. 2 vols., 8vo, 28^.
~^J^^/^/\y>./\y^^^ /\/\ ^^/
3IR WILLIAM HAMILTON ;
Being the Philosophy of Perception : an Analysis. By James Hutchi-
son Stirling, F.R.C.S. & LL.D. Edin. 8vo, 5^.
V /A. '~\j "v r\ /~'^y\ /
A SYSTEM OF LOGIC, RATIOCINATIVE
AND INDUCTIVE;
Being a Connected View of the Principles of Evidence and the Methods of
Scientific Investigation. By John Stuart MiLL. Ninth Edition. 2 vols.
8vo, price 2<^s.
J^ILLICK'S HANDBOOK OF MILL'S LOGIC, price zs. 6d.
gTEBBING'S ANALYSIS OF MILL'S LOGIC, price 3^-. 6d.
atfjokgg Eiiir i\t Crtahmnt 0f gis^ase.
LECTURES ON SURGICAL PATHOLOGY
Delivered at the Royal College of Surgeons of England. By Sir James
Paget, Bart., F.R.S., D.C.L., Oxon., LL.D., Cantab., &c., Serjeant-
Surgeon Extraordinary to the Queen, Surgeon to the Prince of Wales,
Consulting Surgeon to St. Bartholomew^'s Hospital. Third Edition, re-
edited by the Author and W. Turner, M.B., Professor of Anatomy in
the University of Edinburgh. 8vo, with 131 Woodcuts, price 2ls.
pULMONARY CONSUMPTION; ITS NATURE,
VARIETIES, AND TREATMENT :
With an Analysis of One Thousand Cases to exemplify its Duration, By
C. J. B. Williams, M.D., F.R.S., Fellow of the Royal College of Phy-
sicians ; Senior Consulting Physician to the Hospital for Consumption,
Brompton; and by C. T. Williams, M.A., M.D. Oxon.; Fellow of the
Royal College of Physicians; Physician to the Hospital for Consumption,
Brompton. Post 8vo, price lOi-. 6d.
^ TREATISE ON MEDICAL ELECTRICITY,
THEORETICAL AND PRACTICAL;
And its Use in the Treatment of Paralysis, Neuralgia, and other Diseases.
By Julius Althaus, M.D., Member of the Royal College of Physicians ;
Fellow of the Royal Medical and Chirurgical Society ; Senior Physician to
the Infirmary for Epilepsy and Paralysis. Third Edition, enlarged and
revised ; vnth 147 Illustrations engraved on'Wood. 8vo, price iZs.
WORKS ON MEDICINE, SURGERY, &-'C.
]^OTES ON THE TREATMENT OF SKIN
DISEASES.
By Robert Liveing, M.A. and M.D. Cantab., F.R.C.P. Lond., Physi-
cian to Middlesex Hospital, in charge of the Cutaneous Department.
Third Edition, revised and enlarged. i8mo, price 2s. 6d.
.'^\^ V- V ~vy\/
£LEPHANTIASIS GR^CORUM, or TRUE
LEPROSY ;
Being the Goulstonian Lectures for 1873, revised and enlarged. By Robert
Liveing, M.A. and M.D. Cantab., F.R.C.P. London, &c. Crown 8vo,
price 4J-. 6d.
V/-\^\_r«v"V'^/
QN ADDISON'S DISEASE,
Being the Croonian Lectures for 1875, delivered before the Royal College
of Physicians, i-evised and illustrated by Reports of Cases. By E. Headlam
Greenhow, ^LD., F.R.S., F.R.C.P., Physician to, and Lecturer on
Medicine at, the Middlesex Hospital. With 5 Plates of Figures (3 coloured),
Svo, price 12s. 6d.
^ TREATISE ON THE CONTINUED FEVERS
OF GREAT BRITAIN.
By Charles Murchison, M.D., LL.D., F.R.S., &c., Fellow of the
Royal College of Physicians ; Physician and Lecturer on the Principles
and Practice of Medicine, St. Thomas's Hospital. Second Edition,
thoroughly revised and enlarged ; with 5 Chromolithographs, 19 Diagrams
i in Lithography, and 22 Illustrations engraved on Wood. Svo, price 24J.
^YPHOID FEVER;
Its Nature, Mode of Spreading, and Prevention. V^y WiLLlAM BuDD?
M.D., F.R.S. With Four Plates (one coloured). Royal Svo, price i6j-.
LECTURES ON FEVER
Delivered in the Theatre of the Meath Hospital and County of Dublin
Infirmary. By William Stokes, M.D., D.C.L. Oxon., F.R.S., Regius
Professor of Physic in the University of Dublin and Physician-in-Ordinary
to the Queen in Ireland. Edited by J. W. Moore, M.D., F.K.Q.C.P.,
Assistant-Physician to the Cork-Street Fever Hospital, Dublin. Svo,
price 1 5 J.
J^ TREATISE ON GOUT AND RHEUMATIC
GOUT.
By AlkreI") B. Garroi), M.D., I'.R S., &c.. Physician to King's College
Hospital. A New I'Ldition, thoroughly revised, with much additional
practical matter. Svo. [On Moy i.
> y^ rs /% /Nr\ J'V^y^ ^ 'Vr* '^/^ /-»,»»» r\/^r\.
CLi
NICAL RESEARCHES ON DISEASE IN
INDIA.
By Charles Morf.iiead, M.D., Surgeon to the Jamsctjee Jcejeebhoy
Hospital. Second Edition, thoroughly revised, Svo, 21s >
PUBLISHED BY MESSRS. LONGMANS, GREEN, 6^ CO. 7
J)ISEASES OF THE KIDNEY AND URINARY
DERANGEMENTS.
By W. HowsHiP Dickinson, M.D. Cantab., F.R.C.P., &c.. Physician to,
and Lecturer on Pathology at, St. George's Hospital ; Physician to the
Hospital for Sick Children ; Corresponding Member of the Academy of
Medicine of New York. In Three Parts. Part I. — Diabetes, with 3
Plates of Figures and 17 Woodcuts. 8vo, price loj-. 6d.
o
N CONCUSSION OF THE SPINE, NERVOUS
SHOCK, AND OTHER OBSCURE INJURIES OF THE
NERVOUS SYSTEM, in their Clinical and Medico-Legal
Aspects.
By John Eric Erichsen, Senior Surgeon to University College Hospital,
Professor of Clinical Surgery in University College, London, &c. Crown
8vo, price \os. 6d.
DENTAL PATHOLOGY AND SURGERY.
By S. James A. Salter, M.B., F.R.S., Member of the Royal College
of Surgeons, and Examiner in Dental Surgery at the College ; Dental
Surgeon to Guy's Hospital. With 133 Illustrations engraved on Wood.
8vo, price iSj.
' This volume has arrived most opportunely for those practitioners who intend going up for the
L.D.S., and will afford them a fund of information which they will not readily find elsewhere.
We recommend it to their careful perusal, and, we doubt not, it will give pleasure and satisfaction
to the practitioner as well as to students, whether old or young.' — British Journal of Dejital
Science,
\r\/'\.^y.yy./-\/^r\/-\y\j
JNJURIES OF THE EYE, ORBIT, AND EYE-
LIDS ;
Their Immediate and Remote Effects. By George Lawson, F.R.C.S.,
Surgeon to the Royal London Ophthalmic Hospital, Moorfields. 8vo,
with 92 Woodcuts, price J2s. 6c/.
^HE DIAGNOSIS AND TREATMENT OF
DISEASES OF WOMEN, INCLUDING THE DIAGNOSIS
OF PREGNANCY.
By Graily Hewitt, M.D., Professor of Midwifery and Diseases of
Women, University College, and Obstetric Physician to the Hospital ;
Examiner in Obstetric Medicine to the University of London. Third
Edition, revised, and for the most part re-written ; with several additional
Illustrations. 8vo, with 132 Engravings on Wood, price 2^s.
IVORKS ON MEDICINE, SURGERY, &-c.
JOINTS TO MOTHERS FOR THE MANAGE-
MENT OF THEIR HEALTH DURING PREGNANCY
AND IN THE LYING-IN ROOM :
With Hints on Nursing, &c. By Thomas Bull, M.D. New Edition,
revised and enlarged. Fcap. ^s.
'pHE MATERNAL MANAGEMENT OF CHILDREN
IN HEALTH AND DISEASE.
By the same Author. New Edition, revised and enlarged. Fcap. 5j".
ON
THE SURGICAL TREATMENT OF
CHILDREN'S DISEASES.
By Timothy Holmes, Surgeon to St. George's Hospital, and Surgeon-
in-Chief to the Metropolitan Police. Second Edition, thoroughly revised ;
with Additional Chapters on Orthopredic Surgery and Paracentesis Thoracis.
With 9 Chromolithographic Plates and 112 Woodcut Illustrations from
Original Drawings. 8vo, 2is.
\ f^^f^ r\r^r\r\j\ r\r\^r\ r> /> /'\_r\j
LECTURES ON THE DISEASES OF INFANCY
AND CHILDHOOD.
By Charles West, M.D., &c.. Physician to the Hospital for Sick
Children ; Fellow of the Royal College of Physicians. Sixth Edition,
revised and enlarged. 8vo, price i8j".
^HE HANDBOOK FOR MIDWIVES.
By Henry Fly Smith, M.B. Oxon., M.R.C.S., late Assistant-Surgeon
at tlie Hospital for Sick Women, Soho Square. With 41 Woodcuts.
Crown 8vo, price ^s.
npHOMSON'S CONSPECTUS ADAPTED TO
THE BRITISH PHARMACOPOilA.
By Edmund Lloyd Birkett, M.D., Sec, Physician to the City of
London Hospital for Diseases of the Chest. New Edition, Avilh Supple-
ment containing Notices of the New Medicines and Preparations added in
1874 to the British Pharmacopopia. i8mo, 6s.
T^HE ESSENTIALS OF MATERIA MEDICA
AND tiieraim:utics.
By Alfred Baring Garrod, M.D., F.R.S., Fellow of the Royal College
of Physicians ; Professor of Materia Medica and Therapeutics, King's
College, London. Fourth Edition, revised and edited, under the super-
vision of the Author, by F. B. Baxter, M.D., Med. Tutoi King's Coll.
and I'hysician to the Evclinor Hospital for Sick Children. Crown 8vo,
price 12^. 6<f.
PUBLISHED BY MESSRS. LONGMANS, GREEN ^ CO.
D^
PEREIRA'S MATERIA MEDICA AND
THERAPEUTICS,
Abridged, and adapted for the use of Medical and Pharmaceutical Prac-
titioners and Students. Edited by Professor R. Bentley, M.R.C.S.,
F.L.S., and by Professor T. Redwood, Ph.D., F.C.S. With an Ap-
pendix containing the New Medicines included in 1874 by the Medical
Council in the British Pharmacopoeia, and Commentaries thereon by the
Editors. 8vo, with 126 Woodcuts, price 25 j.
Cj^^mbirj*
r)ICTIONARY OF CHEMISTRY AND THE
^^ ALLIED BRANCHES OF OTHER SCIENCES.
By Henry Watts, F.R.S., Editor of the Journal of the Chemical Society,
assisted by eminent Scientific and Practical Chemists. (Including Sup-
plementary Volume of Recent Discoveries, bringing the Record of
Chemical Discovery down to the year 1873.) 7 vols. 8vo, ;i^io ids. 6d.
£LEMENTS OF CHEMISTRY,
Theoretical and Practical. By William Allen Miller, M.D., F.R.S.,
late Professor of Chemistry, King's College, London. Revised, with
Additions, by Herbert Macleod, F.C.S., Professor of Experimental
Science, Indian Civil Engineering College, Cooper's Hill. 3 vols. 8vo.
Part I.— CHEMICAL PHYSICS. 8vo, price 15^.
Part IL— INORGANIC CHEMISTRY, price 21s.
Part III.— ORGANIC CHEMISTRY. New Edition, in the press.
TNTRODUCTION TO THE STUDY OF INORGANIC
CHEMISTRY.
By the same Author. Edited by T. M. Goodeve, M.A. With 71
Figures on Wood, Small 8vo, price 3^'. dd.
QUANTITATIVE CHEMICAL ANALYSIS.
^^ By T. E. Thorpe, Ph.D., F.R.S.E., Professor of Chemistry in the
Andersonian University, Glasgow. Edited by C. .W. Merrifielu, F.R.S.
With 88 Woodcuts. Small 8vo, price 4^. dd.
QUALITATIVE CHEMICAL ANALYSIS AND
^ LABORATORY PRACTICE.
By T. E. Thorpe, Ph.D., F.R.S.E,, Professor of Chemistry in the Ander-
sonian University, Glasgow; and M. M. Pattison Muir. Edited by
C. W. Merrifield, F.R.S. With Plate and 57 Woodcuts. Small 8vo,
price 3.r. dd.
10 WORKS ON MEDICINE, SURGERY, &-c.
INTRODUCTION TO THE STUDY OF OR-
GANIC CHEMISTRY;
The Chemistry of Carbon and its Compounds. By H. E. Armstrong,
Ph.D., Professor of Chemistry in the London Institution. Edited by
C. W. Merrifield, F.R.S. With 8 Woodcuts. Small 8vo, price 3^. 6d,
/^ COURSE OF PRACTICAlTcHEMISTRY,
AiTanged for the use of Medical Students. By William Odling, M.B.,
F. R.S., Fellow of the Royal College of Physicians, Secretary to the
Chemical Society, and Lecturer on Chemistry at St. Bartholomew's
Hospital. Fifth Edition. Crown 8vo, with Woodcuts. [//; the press.
CHEMICAL NOTES™FOR^HE LECTURE
ROOM— ON LIEAT, LAW^S OF CHEMICAL COMBINATION,
AND CHEMISTRY OF THE NON-METALLIC ELEMENTS.
By Thomas Wood, Ph.D., F.C.S. Third Edition. Crown 8vo, Ss.
NOTES ON THE METALS, by the same Author, Second Edition, price 5j-.
'X'EXT-BOOK OF AGRICULTURAL CHE-
MISTRY.
By Robert Warington. Edited by C. W. Merrifield, F.R.S.
Small 8vo. [/;/ the press.
I'EXT-BOOK OF CHEMICAL PHILOSOPHY.
By William A. Tilden, B. Sc. Lond., F.C.S., Lecturer on Chemistry
in Clifton College. Edited by C. W. Merrifield, F.R.S. Small 8vo.
[/« the press.
^EXT-BOOK OF PHOTOGRAPHY.
By Captain Abney, Royal Engineers, F.R.A.S., F.G.S., Instructor in
Chemistry and Photography at the School of Military Engineering, Chat-
ham. Edited by C. W. Merrifield, F.R.S. Small 8vo. [In the press.
gELECT METHODS IN CHEMICAL ANA-
LYSIS, CHIEFLY INORGANIC.
By William Crookes, F.R.S,, F.C.S. , &c. Editor of "The Chemical
News" and of *' The Quarterly Journal of Science." With 22 Woodcuts.
Crown 8vo, price 12s. 6d., cloth.
^ PRACTICAL HANDBOOK OF DYEING
AND CALICO PRINTING.
By W. Crookes, F.R.S., F.C.S., &c. With 11 Page Plates, 49 Speci-
mens of Dyed and Printed Fabrics, and 36 Woodcuts. 8vo, price 42^-.
* rs. /"v/'-vrv vxyxx >-/"\./"\^
INDUSTRIAL CHEMISTRY;
A Manual for Manufacturers and for use in Colleges or Technical Schools,
Being a Translation by Dr. J. D. liAURY of Professors Stohmann and
Englcr's Geitnan Edition of Payen's Precis de Chimie Jndustrielle. Edited
throughout and supplemented with Chapters on the Chemistry of the
Metals by B. H. Paul, Ph.D. In One thick Volume, 8vo, with very
numerous Plates and Woodcuts. [/;/ the press.
PUBLISHED BY MESSRS. LONGMANS, GREEN, ^^ CO. ii
%m\\ti anir Natural Mistorji*
£RANDFS DICTIONARY OF SCIENCE, LITE-
RATURE, AND ART;
Comprising the Definitions and Derivations of the Scientific Terms in
general use, together with the History and Descriptions of the Scientific
Principles of nearly every branch of Human Knowledge. Edited by W.
T. Brande, D.C.L,, F.R.S., LL.D., and the Rev. George W. Cox,
M.A., Author of ' The Aryan Mythology,' &c., assisted by numerous
Contributors. New Edition, revised. 3 vols, medium 8vo, 63^".
vz-vyx/A/xy-s
IJRE'S DICTIONARY OF ARTS, MANUFAC-
TURES, AND MINES;
Containing a clear Exposition of their Principles and Practice. Seventh
Edition, completely revised and greatly enlarged by Robert Hunt,
F.R.S., Keeper of Mining Records, assisted by F. W. Rudler, F.G.S.
and by numerous Contributors. With above 2000 Woodcuts. 3 vols,
medium 8vo, 5/. 5^. od.
\ ntroducti^tT^o^Txperimental
PHYSICS, THEORETICAL AND PRACTICAL ;
Including Directions for Constructing Physical Apparatus and for Making
Experiments. By A. F. Weinhold, Professor in the Royal Technical
School at Chemnitz. Translated and edited (with the Author's sanction)
by B. LoEWY, F.R.A.S. With a Preface by G. C. Foster, F.R.S., Pro-
fessor of Physics in University College, London. Illustrated. 3 Coloured
Plates and 404 Woodcuts. 8vo, price 31^". 6d.
£LEMENTARY TREATISE ON PHYSICS;
Experimental and Applied, for the use of Colleges and Schools. Trans-
lated and edited from Ganot's Elements de Physique (with the Author's
sanction) by E. Atkinson, Ph.D., F.C.S., Professor of Experimental
Science, Staff College, Sandhurst. Seventh Edition, revised and enlarged,
with 4 Coloured Plates and 746 Woodcuts. Post 8vo, price 15^.
PROBLEMS AND EXAMPLES IN PHYSICS.
An Appendix to the Seventh and other Editions of Ganot's ' Elementary
Treatise.' 8vo, price \s.
]^ATURAL PHILOSOPHY FOR GENERAL
READERS AND YOUNG PERSONS ;
Being a Course of Physics divested of Mathematical Formulae, and ex-
pressed in the language of daily life. Translated from Ganot's Cours de
Physique {yN'\\\\ the Author's sanction) by E. Atkinson, Ph.D., F.C.S.
Second Edition, carefully revised ; with 20 pages of New Matter, 2
Coloured Plates, and 429 Woodcuts, of which 24 are New in this Edition.
Crown 8vo, price ']s. 6d.
«E CORRELATION OF PHYSICAL FORCES.
Sixth Edition, with other contributions to Science. By the Plon. Sir W.
R. Grove, M.A., F.R.S., one of the Judges of the Court of Common
Pleas. 8vo, price 15^,
12 WORKS ON MEDICINE, SURGERY, -^c.
/^N ELEMENTARY EXPOSITION OF THE
DOCTRINE OF ENERGY.
By D. D. Heath, M.A., Fellow of Trinity College, Cambridge. Post
8vo, 4^. 6d.
^IR AND RAIN;
The Beginnings of a Chemical Climatology. By Robert Angus Smith,
Ph.D., F.R.S., F.C.S. (General) Inspector of Alkali Works for the Govern-
ment. AVith 8 Illustrations. 8vo, price 24J.
^IR AND ITS RELATIONS TO LIFE;
Being, with some Additions, the substance of a Course of Lectures delivered
at the Royal Institution of Great Britain in 1874. By Walter Noel
Hartley, P\C.S., Demonstrator of Chemistry at King's College, London.
With 66 Woodcut Illustrations. Small 8vo, price 6s.
fJEAT A MODE OF MOTION.
By John Tyndall, LL.D., D.C.L., F.R.S., Professor of Natural Philosophy
in the Royal Institution of Great Britain. Fifth Edition, with Plate and
1 10 Woodcuts. Crown 8vo, price lOj-. 6d.
5OUND.
By the same Author, Third Edition, revised and augmented, including
Recent Researches in Fog-Signalling ; with Portrait and 190 Woodcuts
and Diagrams. Crown Svo, price los. 6d.
LECTURES ON LIGHT delivered in America in 1872
and 1873. I^y the same Author. Second Edition, with Portrait engraved
on Steel, i Lithographic Plate, and 59 Diagrams. Crown Svo, price 7.^. 6d.
CONTRIBUTIONS TO MOLECULAR PHYSICS
^^ IN THE DOMAIN OF RADIANT HEAT.
By the same Author. With 2 I'lates and 31 Woodcuts. Svo, price \6s.
"DESEARCHES on DIAMAGNETISM AND MAGNE-
•^^ C RYSTALLIC ACTION ; including the Question of Diamagnetic Polarity.
By the same Author. With 6 Plates and many Woodcuts. Svo, price 14^.
TSJOTES OF A COURSE OF SEVEN LECTURES
■^^ on ELECTRICAL PHKNOMENA AND TI-n:ORIES. By the
same Author. Crown Svo, i)ricc \s. sewed, or \s. 6d. cloth.
"PSjOTES OF A COURSE OF NINE LECTURES ON
"^ LIGHT. By the same Author. Crown Svo, is. sewed, or is. 6d. clotli.
pRAGMENTS OF SCIENCE.
•^ By the same Author. New Edition, lacing the Third, tlioroughly revised,
with a New Preface. Crown Svo, price loj. 6d.
/N/^./ »^>^ V/\
A SHORT MANUAL OF HEAT FOR THE USE
OF SCHOOLS AND SCIENCE CLASSES. By the Rev. A. Irvi.ng,
B.A. and B.Sc, Second Master of the High School, Nottingham. With
33 Diagrams. Small Svo, price 2.r. 6if.
PUBLISHED BY MESSRS. LOXG.VAiVS, GREEiY, &- CO.
'^pHEORY OF HEAT.
By J. Clerk Maxwell, M.A., LL.D. Edin., F.R.SS. L. & E., Professor
of Experimental Physics in the University of Cambridge. Edited by T. M.
GooDEVE, M.A. With 41 Woodcuts and Diagrams. Small 8vo, price
v. ^d. cloth.
r\^'''K/ \y '-' \^"v-' v vv.- \ / \ /~N. r\.' \y \
gRINKLEY'S ASTRONOMY.
o
Revised and partly re-written. By J. W. SxUBBS, D.D., Fellow and
Tutor of Trinity College ; and F. Brunnow, Ph.D. Professor of Astronomy
in the University of Dublin. With Additional Chapters and Questions for
Examination. Second Edition, enlarged and improved. Crown 8vo, with
Diagrams, price 6s.
UTLINES OF ASTRONOMY.
By Sir John F. W. Herschel, Bart., K.H., &c., Member of the Insti-
tute of France. Twelfth Edition, with 9 Plates, and numerous Diagrams.
Square crown 8vo, price 12s.
(^ELESTIAL OBJECTS FOR COMMON TE-
LESCOPES.
By the Rev, T. W. Webb, M.A,, F.R.A.S., Incumbent of Hardwick,
Herefordshire. New Edition, thoroughly revised ; with Map of the Moon
and numerous Woodcuts. Crown Svo, price yj. 6(/.
JS^ NEW STAR ATLAS,
For the Library, the School, and the Observatory, in Twelve Circular Maps
(with Two Index Plates). Intended as a Companion to ' Webb's Celestial
Objects for Common Telescopes.' With a Letterpress Introduction on the
Study of the Stars, illustrated by 9 Diagrams. By RiCHARD A. Proctor,
B.A., Hon. Sec. R.A. S. Crown Svo, price ^s.
/ Wvy-\y-xy"V./-v/X>^\>xy-\./
gPECTRUM ANALYSIS
In its Application to Terrestrial Substances and the Physical Constitution of
the Heavenly Bodies. Familiarly explained by Dr. H. Schellen,
Director der Realschule, Cologne. Translated from the German by Jane
and Caroline Lassell; edited, with Notes, by W. Huggins, LL.D.,
F. R.S. With 13 Plates (6 Coloured), including Angstrom's and Kirchhoffs
Maps, and 223 Woodcuts. Svo, price 28i'.
npHE TRANSITS OF VENUS;
A Popular Account of Past and Coming Transits, from the first observed
l)y Ilorrocks A.D, 1639 to the Transit of a.d. 2012. By R. A. Proctor,
B. A. With 20 Plates (12 Coloured) and 37 Woodcut Illustrations. Crown
Svo, price Ss. 6d.
14 WORKS ON MEDICINE, SURGERY, &-c.
'^HE MOON^ and the Condition and Configurations of
its Surface. By Edmund Neison, Fellow of the Royal Astronomical
Society, &c. In One Volume, 8yo, illustrated by Maps and Plates,
l^A^em-ly ready.
'^HE MOON; her Motions, Aspect, Scenery, and
Physical Condition. By RiciiARD A. Proctor, B.A, With 22 Litho-
graphic Plates, Charts, and Diagrams, i Wood Engraving, and 3 Lunar
Photogi'aphs by Rutherfurd, of New York. Crown 8vo. Price i^s.
T
HE SUN: RULER, LIGHT, FIRE, and LIFE OF
THE PLANETARY SYSTEM.
By Richard A. Proctor, B.A. Second Edition, revised ; with 10 Plates
(7 coloured) and 106 Figures engraved on Wood. CroAvn 8vo, price 14J.
QTHER WORLDS THAN OURS;
The Plurality of Worlds Studied under the Light of Recent Scientific
Researches. By R. A. Proctor, B.A. Third Edition, revised and
enlarged ; with 14 Illustrations (6 coloured). Crown 8vo, price los, 6d.
'PHE ORBS AROUND US;
A Series of Familiar Essays on the Moon and Planets, Meteors and Comets,
the Sun and Coloured Pairs of Suns. By Richard A. Proctor, B.A.
Second Edition, with Chart and 4 Diagrams. Crown 8vo, price 7^. 6d.
JgSSAYS ON ASTRONOMY:
A Series of Papers on Planets and Meteors, the Sun and sun-surrounding
Space, Stars, and Star Cloudlets ; and a Dissertation on the approaching
Transit of Venus. By the same Author. With 10 Plates and 24 Wood-
cuts. 8vo, price I2s.
IGHT SCIENCE FOR LEISURE HOURS;
A Series of Familiar Essays on Scientific Subjects, Natural Phenomena, See.
By the same Author. First and Second Series. Crown 8vo, 7^. bd. each.
L
pRAGMENTARY PAPERS ON SCIENCE and
other Subjects. By the late Sir Henry Holland, Bart., M.D., &c.
Edited by his Son, the Rev. Francis J. Holland. 8vo, price 14J.
A
HANDBOOK OF PRACTICAL TELE-
GRAPHY.
By R. S. CuLLEY, Member Inst. C.E., Engineer-in-chief of Telegraphs to
the Post Office. The Sixth Edition, revised and enlarged ; with 144 Wood-
cuts and 5 Lithographic Plates of Apparatus. 8vo, price i6j.
V/X^V^^y v,^\,y-v./>yV/V
'^EXT-BOOK OF TELEGRAPHY.
By W. H. Preece, C.E., Divisional Engineer, P.O. Telegraphs; and
J. SlVEWRlGliT, M.A., Superintendent (Engineering Department) P.O.
Telegraphs. Edited by C. \V. Mekrimkli;, F.R.S. With 160 Figures
and Diagrams engraved on wood. Small 8vo, 3.C Od.
PUBLISHED BY MESSRS. LONGMANS, GREEN, &- CO. 15
'^EXT-BOOK OF MINERALOGY.
By H. Bauerman, Museum of Practical Geology. Edited by C. W.
Merrifield, F.R.S. Small 8 vo. [In the press,
lyTETALS, THEIrTrOPERTIES and TREAT-
MENT.
By Charles Loudon Bloxam, Professor of Chemistry in King's College,
London ; Professor of Chemistry in the Royal Military Academy and in
the Department of Artillery Studies, Woolwich. Edited by T, M.
GooDEVE, M.A., With 105 Figures on Wood. Small 8vo, price 3J-. 6d.
jyjANUAL OF^FaCTK^iTaSSAYING.
By John Mitchell, F. C. S. Fourth Edition, in which are incorporated
all the recent valuable improvements in Assaying ; including Volumetric
and Colorimetric Assays, and the Blowpipe Assays. Edited and re-written
by W. Crookes, F.R.S., with 199 Figures and Diagrams engraved on
wood. 8vo, price 3 1 J-. 6d.
^ PRACTICAL TREATISE ON METALLURGY,
Adapted from the last German Edition of Professor Kerl's Metallurgy,
by William Crookes, F.R.S., and Ernst Rohrig, Ph.D. 3 vols.
8vo, price 4/. l^s.
npHE TREASimF6inBOTAN% OR POPULAR
DICTIONARY OF THE VEGETABLE KINGDOM;
With which is incorporated a Glossary of Botanical Terms. Edited by
J. LiNDLEY, M.D., F.R.S., and T. Moore, F.L.S., assisted by numerous
Contributors. With 20 Steel Plates, and numerous Woodcuts from Original
Designs by W. H. Fitch. 2 Parts, fcap. 8vo, \2s.
LOUDON'S ENCYCLOPAEDIA OF PLANTS:
Comprising the Specific Character, Description, Culture, History, Applica-
tion in the Arts, and every other desirable particular respecting all the
plants indigenous to, cultivated in, or introduced into, Britain. Corrected
by Mrs. Loudon. 8vo, with above 12,000 Woodcuts, price 42^.
r)ECAISNE & LE MAOUT'S GENERAL SYS-
TEM OF DESCRIPTIVE AND ANALYTICAL BOTANY.
Translated from the French by Mrs. Hooker. The orders arranged after
the method followed in the Universities and Schools of Great Britain, its
Colonies, America, and India, with Additions, an Appendix on the Natural
Method, and a Synopsis of the Orders, by J. D. Hooker, C.B., F.R.S.,
&c. , Director of the Royal Botanic Gardens, Kew. With 5, 500 Woodcuts
from Designs by L. Stenheil and A. Riocreux. Imperial 8vo, price 31J. dd.
'J'EXT-BOOK OF STRUCTURAL AND PHY-
SIOLOGICAL BOTANY.
By Dr. O. W. T110M6, Ordinary Professor of Botany at the School of
Science and Art, Cologne. Translated and edited by A. W. Bennett,
M.A., B. Sc, F.L.S., &c., Lecturer on Botany at St. Thomas's Hospital.
\In the press.
n^n\
Abney's Text-Book of Photography lo
Althaus's Medical Electricity
Armstrong's Organic Chemistry
Bain on the Emotions and ^Vill
on Mental and Moral Science
on the Senses and Intellect
's Logic .....
5
lO
4
4
4
4
Bauerman 's Text-Book of M ineralogy 1 5
Bloxam on Metals . . . . 15
Brande's Dictionary of Science,
Literature, and Art . . .11
Brinkley's Astronomy . . . 13
Buckton's Physiological Lectures . 3
Budd on Typhoid Fever . . 6
Bull's Hints to Mothers . . . 8
Management of Children . 8
Cooke's Tablets of Anatomy and
Physiology ... .2
Copland's Dictionary of Medicine 4
Crookes on Chemical Analysis , .10
Handbook on Dyeing . 10
Culley's Plandbook of Telegi-aphy . 14
Decaisne and Le Maout's Botany . 15
Dickinson on Diseases of the Kidney 7
Erichsen on Concussion of the Spine 7
• 's Hospitalism . • • 3
Surgery . . .1
Ganot's Natural Philosophy . .II
Physics . . . .11
Problems and Examples in
Physics . . . . .11
Garrod on Gout . . . . 6
Garrod's Materia Medica . . 8
Gray's Anatomy . . . . 2
Greenhow on Addison's Disease . 6
Grove's Correlation of Physical Forces 1 1
12
12
13
7
14
I
8
4
12
15
5
7
4
15
6
6
2
13
5
9
9
15
Hartley on Atmospheric Air
Heath on Doctrine of Energy
Herschel's Outlines of Astronomy
Hewitt on the Diseases of Women
Holland's Fragments on Science
Holmes's Surgery
. Surgical Diseases of Infancy
Husband's Examination Questions
Irving's Manual of Heat .
Kerl's Metallurgy .
Killick's Handbook of Mill's Logic
Lawson on Injuries of the Eye .
Lewes's History of Philosophy
Lindley's Treasury of Botany
Liveing on Skin Diseases
Leprosy .
Loudon's Encyclopccdia of Plants
Marshall's Outlines of Physiology
Maxwell's Theory of Heal
Mill's System of Logic .
Miller's Elements of Chemistry
Inorganic Chemistry
Mitclicll's Assaying
Morehead on Disease in India
Murchison on Continued Fevers
Xeison on the Moon . . . .
Odling's Practical Chemistry .
Owen's Comparative Anatcjmy ami
Physiology of Vertebrala .
Owen's Lectures on the Invertebrata
Paget's Clinical Lectures and Ad-
dresses . . ...
Paget's Surgical Pathology
Payen's Industrial Chemistry.
Pereira's Elements of Materia Medica
Preece and Sivewright's Telegraphy 14
Proctor on Plurality of Worlds
on the Sun
Proctor's Astronomical Essays .
Moon ....
New Star Atlas . . .
Orbs Around us
Scientific Essays .
Transits of Venus
Quain's Anatomy ....
Medical Dictionary .
Salter's Dental Patholog}' & Surgery
Schellen's Spectrum Analysis
Smith's Air and Rain
Handbook for Mid wives
Stebbing's Analysis of Mill's Logic
Stirling's Hamilton . . . .
Secret of Hegel
Stokes on Fever . . . .
Thome's Stnicturaland Physiological
Botany .....
Thomson's Conspectus, by Birkett .
Thorpe's Quantitative Analysis .
Thorpe & Muir's Qualitative Analysis
Tilden's Chemical Philosophy
Tyndall on Diamagnetism . . .
Tyndall's Fragments of Science
Lectures on Heat . .
Light .
Sound
Molecular Physics
Notes on Electricity
Notes on Light
6
6
14
lO
n
o
5
10
9
14
14
14
14
n
14
14
13
2
4
7
13
12
8
5
5
5
6
8
9
9
, 10
12
. 12
. 12
12
, 12
, 12
, 12
, 12
Ure's Dictionary of Arts, Manufac-
tures, and Mines . . . 1 1
Warington's Agricultural Chemistry 10
Watson's Principles and Practice of
Physic ..... 3
Watts's Dictionary of Chemistry . g
Webb's Celestial Objects for Com-
mon Telescopes . . .13
Wcinhold's Experimental Physics . 1 1
West on the Diseases of Children . 8
Williams on Pulmonary Consumption 5
Wood's Chemical Notes . . 10
Notes on the Metals . .10
BRADDUBY, AONF.W, & CO., PRINTK.RS, W'HITFFniAnS.
X
■••■.■;■■'■■: ■■r.-t: ' -i,!! 7;> ' 'Ji v. .■ f.M ■ i ■•■■.'
Live Music
Archive
Librivox
Free Audio
Metropolitan Museum
Cleveland
Museum of Art
Internet
Arcade
Console Living Room
Open Library
American
Libraries
TV News
Understanding
9/11